case study project

1. Case Study Project
Aysha Taylor
Clinical Practice 1
MLT-2015-81988
Professor Martinez
December 11th, 2022

2. Patient Information

3. Patient Information
Demographics:
Sex: Male
DOB: 02/20/1939
Age: 83
Signs and symptoms:
• Cough
• Back pain
History:
• Smoking: Y
• Drinking: N
Location: Intensive Care Unit (ICU)
Length of stay: 5 days

4. Results

5. CMP Results
Clinical Implications:
• ↑ Glucose= Diabetes
• ↑ BUN and Creatinine= kidney
disease, dehydration,
gastrointestinal bleeding
• ↑ Cl= kidney disease, metabolic
acidosis
• ↓ CO2= metabolic acidosis
• ↓ Total protein and albumin=
malnutrition, liver or kidney disease
• ↑ Anion Gap= metabolic acidosis

6. Urinalysis Results
Clinical Implications:
• + Blood= UTI, kidney stones, kidney
disease
• + Protein= kidney disease
• + Leukocyte Esterase= UTI
• ↑ WBCs= UTI
• ↑ Casts (Hyaline)= kidney disease
• + Bacteria= UTI

7. CBC Results
Clinical Implications:
• ↑WBC= possibly due to blood
transfusions, infection
• ↓ RBC= Anemia, vitamin B or
folate deficiency, excessive
blood loss
• ↓H & H (critical)= same as RBC
• ↑MCV/↓ MCHC=
Macrocytic/Hypochromic RBCs
• ↓ Platelets= Anemia, excessive
blood loss
• ↑ Neutrophils= infection

8. Troponin Results
Troponin,
High Sensitivity
Date: 11/26/22
Time: 2035
Date: 11/27/22
Time: 0441
Troponin
Reference (3-59 ng/L)
87 H 83 H
Clinical Implications:
• ↑ Troponin= Acute
Myocardial Injury (AMI)

9. Blood Products &
Medication

10. Blood Products

11. Medication
Medication Drug Class Reason for Use Clinical Implications
from Case Study
Propofol General Anesthetic Sedation Possible surgery
Promethazine HCl Phenothiazine Derivatives Nausea/Vomiting Metabolic Acidosis
Norepinephrine Bitartrate Alpha/Beta Adrenergic
Agonists
Hypotension Anemia, excessive blood
loss
Nitroglycerin Nitrates and Nitrites Chest pain AMI
Piperacillin/Tazobactam/
Dextrose
Penicillin UTI UTI
Naloxone HCl Opiate antagonists Opiate reversal Smoking history
Fentanyl Citrate Opiate agonist Pain Smoking history
Glucagon Glycogenolytic agents Hypoglycemia Diabetes
Budesonide Corticosteroid Chronic Pulmonary
Obstruction
AMI
Dextrose Caloric agent Hypoglycemia Diabetes

12. Probable Diagnosis

13. Probable Diagnosis
The results from the previous tests indicates the following diagnoses:
• UTI (+ for bacteria, WBC, blood in urinalysis)
• Diabetes (High glucose and use of glucagon)
• Kidney Disease (High BUN, creatinine, chloride/ low protein, albumin)
• Metabolic Acidosis (Low CO2/ high Cl and anion gap)
• Anemia (Critically low H&H/ low RBCs and PLTs)
• Infection (High Neutrophils)
• AMI (High Troponin)

14. Pictures & Prognosis

15. Pictures & Prognosis
With continued blood
transfusions and use of
medications, the patient is
expected to recover.

16. References

17. References
Anion gap blood test: What it is, purpose, risks & results. Cleveland Clinic. (n.d.). Retrieved
December 10, 2022, from https://my.clevelandclinic.org/health/diagnostics/22041-anion-gap-
blood-test#:~:text=What%20does%20a%20high%20anion,Dehydration.
Blood urea nitrogen (BUN) test. (n.d.). Retrieved December 10, 2022, from
https://lajollasurgical.com/health-library/hw-
view.php?DOCHWID=aa36271#:~:text=High%20BUN%2Dto%2Dcreatinine%20ratios,digestive%20
tract%20or%20respiratory%20tract.
Izbicki G;Rudensky B;Na'amad M;Hershko C;Huerta M;Hersch M; (n.d.). Transfusion-related
leukocytosis in critically ill patients. Critical care medicine. Retrieved December 9, 2022, from
https://pubmed.ncbi.nlm.nih.gov/14758161/#:~:text=The%20white%20blood%20cell%20count,h
rs%20following%20transfusion%20(p%20%3C.
Leukocyte Esterase urine test. Mount Sinai Health System. (n.d.). Retrieved December 9, 2022,
from https://www.mountsinai.org/health-library/tests/leukocyte-esterase-urine-
test#:~:text=Leukocyte%20esterase%20is%20a%20screening,that%20point%20to%20an%20infect
ion.

18. References
NHS. (n.d.). NHS choices. Retrieved December 10, 2022,
from https://www.nhs.uk/conditions/red-blood-
count/#:~:text=A%20low%20RBC%20count%20could,to%20meet%20their%20body's%20
needs).
There's blood in my urine. is it serious? Jefferson Health. (n.d.). Retrieved December 9,
2022, from https://www.jeffersonhealth.org/your-health/living-well/there-is-blood-in-
my-urine-is-it-serious
Transfusion-related leukocytosis in critically ill patients. (n.d.). Retrieved December 10,
2022, from https://www.researchgate.net/publication/8890576_Transfusion-
related_leukocytosis_in_critically_ill_patients
U.S. National Library of Medicine. (n.d.). Chloride blood test: Medlineplus medical test.
MedlinePlus. Retrieved December 10, 2022, from https://medlineplus.gov/lab-
tests/chloride-blood-test/