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Two Case Scenarios for the Respiratory Students

Posted Feb 01 2010 1:08pm

I know there are a couple dozen RT students across the crountry who read this blog and I appreciate that.  I know that I'm not like other RT blogs and I don't usually present a lot of clinical information, I use this blog more as a place to put up things that strike me as funny or show the more quirky human side of the job.

But today will be different. I'm going to put up two Case scenarios that I have experienced recently (with non-important details changed for HIPAA reasons) that I want you to look at because you're going to deal with these things on just about every shift.  I want you to look at them and tell me what the problem is and what the solution is, or in other words, had you been the Assess & Treat RT what would you have done?

 If you're shy and don't want to put it in the comments section, shoot me an email at Marie9949(at)  I'm not trying to make anyone look stupid so if you're wrong I won't post your answer and if you're wrong in the comment section, I promise I'll delete. Like I said, I'm not trying to embarrass anyone. These two cases are things that we deal with every single shift so it's important!

Case #1

Resp Assess & Treat ordered on 60 yr-old male presented to the ER with SOB (shortness of breath) that has been increasing for three days and general dull chest pain.

Dx (Diagnosis):  COPD exacerbation

Hx (History):  COPD, CHF (congestive heart failure), HTN (hypertension), Diabetes, former smoker from more than 10 years ago.

Meds:  Metoprolol, Bumex, No daily COPD maintenance drugs but a PRN albuterol mdi that the pt's wife states he hasn't used in so long they don't know where it is, Zocor, metformin, fish oil.

CXR: Enlarged heart, vascular congestion, pulmonary edema, fluid in fissures (radiologist stated that the fluid was present but not in quantity large enough to be considered a true pleural effusion).

Clinical presentation: Obese barrel-chested non-ambulatory male sleeping with HOB at 50-55 degrees.  BS (breath sounds): extremely dimished with no rales, wheezes, or rhonchi, RR 12-16, pt states that he feels "okay" but he's "more SOB than usual" and his chest feels "funny...different". Wife states he's been "more anxious than usual the last couple of days".  BP 117/60, HR (heart rate): 62, SpO2 96% on 3 l/m n/c home O2, skin color appeared normal for the pt.  Peripheral edema "a little worse than normal" according to wife.

Treatment up to this point was two back-to-back albuterol nebs in the ER. When I asked "Did that seem to help?"  Pt's response was a shrug and "Yeah, I guess. Didn't hurt or anything."

What's the problem? What's the solution?  What would you do?

Case #2

70 yr-old woman presents to the ER by family who say that they went to visit and found her disoriented and slurring. They have no idea how long she'd been this way.  No one had talked to her in person or on the phone in a few days.

Dx:  Stroke

Hx:  COPD, former smoker who had quit many years ago, kidney disease, diabetes, HTN, no former hx of stroke

Medications:  Peritoneal dialysis, BID Combivent mdi, don't remember the exact HTN drug(s), metformin, multivitamin.

CXR from day before:  No acute pulmonary processes

Clinical presentation:  RN called and asked if we could come take a look.  PT had already been set up on Q4WA albuterol nebs the day before and had been given last tx of the day 3 hours prior.  RN stated that over the last couple of hours since pt's last tx she'd developed a "gurgle" low in her throat, her oxygen had been turned up from 2 l/m to 4 l/m, and her RR had increased to mid-high 20's.  Pt was normal weight woman with HOB (head of bed) flat, responsive to commands but non-verbal, coughed on command for large clear/white sputum sx'ed orally.  BS:  diminished with rales throughout bases,  particularly on side she was laying on, and wheezing in every lung field.  HR: 90, BP 125/70's, RR: 28-30, skin appeared normal or could have been pale, slightly clammy. RN stated pt had been increasingly restless and frequently moaned. SpO2 88% on 4 l/m but pt was breathing through her mouth. RN stated that last dialysis had been 5 hours prior, that she was urinating "some" and that "I/O's are even so it can't be fluid from the dialysis".  I checked I/O's and asked where the numbers for the dialysis fluids had been put in. Only the IV fluid numbers had been recorded.

I brought the HOB up to 30 degrees, placed her on a 50% VM for SpO2 of 90% and since it had been 3 hours since her last neb tx, I gave a tx. Her response was no change in BS or RR, HR increased to 100.  She increased moaning. Still responding to commands but not spontaneously verbal or communicative.

What's the problem? What's the solution?  What would you do now?

Eventually, I'll tell you the end of the stories.

So, students, what would you do?  (And yes, SoonerFan, I want your input eventually too. Always. :-))

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