Professional Documents
Culture Documents
Matthew Igbinigie SOM, Tracey Isidro SOM, Ennert Manyeza SHP, Kathryn Laskowski SOM,
UT Medical Branch at
Scenario:
Galveston
Initial Evaluation:
Take HPI and perform Physical Exam.
Put orders in for diagnostic studies/ medications:
CXR for pneumonia
Culture confirm diagnosis and cause of
pneumonia
Blood gas, BMP, and BNP levels
Place order to call respiratory - Pt is
hypoventilating since Pt is hypoxemic (Sat
78%) and hypercapneic (PCO2 = 55 mEq/L)
Physical Exam:
Temp 101.2 F
(Oral)
RR 24 breaths/min
Pulse 110/min
BP 80/68
SPO2 78% on room air
Assessment:
Evaluate labs, vitals and physical exam - devise a
differential diagnosis:
BNP is elevated at 300 pg/mL: possible heart
failure
Pt is hypotensive at 80/68 mmHg and
tachycardic at 110 bpm. Possible causes are
bacteremia or sepsis.
Assess renal function: BUN elevated at 25
ng/dL and Cr elevated at 2.0 mg/dL
Pt is hypernatremic: Place order for IV fluids
Place IV line and give fluids
Encourage Pt to stop smoking; Explain the reason
why he should stop smoking i.e. smoking can
cause lung cancer, can decrease the bodys
mucociliary escalator, and increase risk of
pneumonia
Explain to the Pt the reason why he should stop
drinking possible cause of his enlarged liver
i.e. can cause cirrhosis, liver cancer
Disposition:
Maintain open communication with other
health professionals to ensure constant care
and accurate and updated information.
Admit patient for (+) Strep Pneumo, and
further evaluation of sepsis, CHF, and kidney
failure.
Once patients breathing is stable without
assistance, and If no prior medical history is
available, consider having patient undergo
spirometry-> this will indicate the presence of
an obstructive/restrictive defect, the severity,
and if bronchodilator therapy will have a
positive effect in the future.