Instructions · This week’s case study will introduce concepts related to the pulmonary system and shock states. Read the scenario and thoroughly complete the questions. Some of the answers will be short answers and may not require a lot of details. For example: what is the most common organism to cause a hospital acquired infection? The answer is pseudomonas aeruginosa. Answers to questions that relate to the pathogenesis of a disease must include specific details on the process. For example: How does hypoxia lead to cellular injury? Simply writing that a lack of blood flow, causes a lack of oxygen available to the cell and the cell cannot function without oxygen is not sufficient. This type of response is NOT reflective of an advanced understanding of the concept or graduate level work. This answer should discuss the cascade of events leading to the lack of oxygen and how it specifically impairs cellular function. All answers to these type of questions should address the effects at the cellular level, then the effects on the organ and then the body as a whole. Additionally describing the normal anatomical and/or physiologic processes underlying the pathogenesis will be necessary to thoroughly answer the question. It is very likely that you will need to reference multiple sources to answer the questions thoroughly. Your text book will not necessarily have all the answers. Only professional sources may be used to complete the assignment. These include text books, primary and secondary journal articles from peer reviewed journals, government and university websites, and publications from professional societies who establish disease management guidelines and recommendations. Sources such as Wikipedia or other generic websites are not considered professional references and should not be used to complete the case studies. · Reason for Consultation: Desaturation to 64% on room air 1 hour ago with associated shortness of breath. History of Present Illness: Mrs. X is 73-year-old Caucasian female who was admitted to the general surgery service 3 days ago for a leaking j-tube which was surgically replaced 2 days ago. This morning at 07:30, the RN reported that the patient was sleeping and doing fine, then the CNA made rounds at 0900 and Mrs. X was found to be mildly dyspneic.  Vital signs were checked at that time and were; temperature 38.6, pulse 120, respirations 20, blood pressure 138/38.  O2 sat was 64% on room air.  The general surgeon was notified by the nursing staff of the hypoxia, an order for a chest x-ray and oxygen therapy were given to the RN. The O2 sat is maintaining at 91-92% on 4L NC. The patient was seen and examined at 10:10 a.m.  She reported that she has had mild dyspnea for 2 days that has progressively gotten worse. She does not use oxygen at home.  Her respiratory rate at the time of this visit was 20 and she feels short of breath. She has felt this way in the past when she had pneumonia.  She is currently undergoing radiatio.

1. Instructions
· This week’s case study will introduce concepts related to the
pulmonary system and shock states. Read the scenario and
thoroughly complete the questions. Some of the answers will be
short answers and may not require a lot of details. For example:
what is the most common organism to cause a hospital acquired
infection? The answer is pseudomonas aeruginosa. Answers to
questions that relate to the pathogenesis of a disease must
include specific details on the process. For example: How does
hypoxia lead to cellular injury? Simply writing that a lack of
blood flow, causes a lack of oxygen available to the cell and the
cell cannot function without oxygen is not sufficient. This type
of response is NOT reflective of an advanced understanding of
the concept or graduate level work. This answer should discuss
the cascade of events leading to the lack of oxygen and how it
specifically impairs cellular function. All answers to these type
of questions should address the effects at the cellular level, then
the effects on the organ and then the body as a whole.
Additionally describing the normal anatomical and/or
physiologic processes underlying the pathogenesis will be
necessary to thoroughly answer the question.
It is very likely that you will need to reference multiple sources
to answer the questions thoroughly. Your text book will not
necessarily have all the answers. Only professional sources may
be used to complete the assignment. These include text books,
primary and secondary journal articles from peer reviewed
journals, government and university websites, and publications
from professional societies who establish disease management
guidelines and recommendations. Sources such as Wikipedia or
other generic websites are not considered professional
references and should not be used to complete the case studies.

2. · Reason for Consultation:
Desaturation to 64% on room air 1 hour ago with associated
shortness of breath.
History of Present Illness:
Mrs. X is 73-year-old Caucasian female who was admitted to
the general surgery service 3 days ago for a leaking j-tube
which was surgically replaced 2 days ago. This morning at
07:30, the RN reported that the patient was sleeping and doing
fine, then the CNA made rounds at 0900 and Mrs. X was found
to be mildly dyspneic. Vital signs were checked at that time
and were; temperature 38.6, pulse 120, respirations 20, blood
pressure 138/38. O2 sat was 64% on room air. The general
surgeon was notified by the nursing staff of the hypoxia, an
order for a chest x-ray and oxygen therapy were given to the
RN. The O2 sat is maintaining at 91-92% on 4L NC. The patient
was seen and examined at 10:10 a.m. She reported that she has
had mild dyspnea for 2 days that has progressively gotten
worse. She does not use oxygen at home. Her respiratory rate at
the time of this visit was 20 and she feels short of breath. She
has felt this way in the past when she had pneumonia. She is
currently undergoing radiation treatment for laryngeal cancer
and her last treatment was 1 to 2 weeks ago. She reported that
she has 2 to 3 treatments left. She denied any chest pain or
previous history of CHF. Review of her vital signs showed that
she had been having intermittent fevers since yesterday
morning. Of note, she was admitted to the hospital 3 weeks ago
for an atrial fibrillation with RVR for which she was
cardioverted and has not had any further problems. The
cardiologist at that time said that she did not need any
anticoagulation unless she reverted back into A-fib.
Review of Systems:
Constitutional: Negative for diaphoresis and chills. Positive
for fever and fatigue.
HEENT: Negative for hearing loss, ear pain, nose bleeds, and
tinnitus. Positive for throat pain secondary to her laryngeal
cancer.

3. Eyes: Negative for blurred vision, double vision, photophobia,
discharge and redness.
Respiratory: Positive for cough and shortness of breath.
Negative for hemoptysis and wheezing.
Cardiovascular: Negative for chest pain, palpitations,
orthopnea, leg swelling and PND.
Gastrointestinal: Negative for heartburn, nausea, vomiting,
abdominal pain, diarrhea, constipation, blood in stool and
melena.
Genitourinary: Negative for dysuria, urgency, frequency,
hematuria and flank pain.
Musculoskeletal: Negative for myalgias, back pain and falls.
Skin: Negative for itching and rash.
Neurological: Negative for dizziness, tingling, tremors, sensory
change and speech changes.
Endocrine/hematologic/allergies: Negative for environmental
allergies or polydipsia. Does not bruise or bleed easily.
Psychiatric: Negative for depression, hallucinations and
memory loss.
Past Medical History:
1. Diabetes mellitus that was diagnosed 12 years ago with
neuropathy. This resolved after gastric bypass surgery, which
she had approximately 3 years ago.
2. Laryngeal cancer
3. Hypertension
4. Hypercholesterolemia
5. Pneumonia
6. Arthritis
7. Hypothyroidism

4. 8. Atrial fibrillation
9. Acute renal failure
10.Chronic kidney disease, stage IV – 4 months ago a renal
biopsy was completed, which showed focal acute tubular
necrosis and patchy tubular atrophy, moderate to severe
interstitial fibrosis with patchy acute and chronic interstitial
nephritis, normal cellular glomeruli with no white microscopic
evidence of a primary glomerulopathy. Baseline creatinine is
1.9.
11.Peptic ulcer disease
12.Skin cancer
13.Anemia
14.Osteoporosis
Past Surgical History:
15.Gastric bypass 4 years ago
16.Closure of mesenteric defect.
17.Radical neck resection on 1 year ago.
Family History:
18.Mother had diabetes diagnosed at age 55 and high blood
pressure. Deceased.
19.Father had heart disease diagnosed at age 60. Deceased.
20.She had a sister with diabetes, thyroid disease, CKD, on

5. dialysis, with unknown etiology.
Social History:
She denies any smoking or alcohol use. She denies any drug
use.
Medications:
21.Calcitriol 0.5 mcg PO every other day
22.Vitamin B12 2500 mcg sublingual every Monday and
Thursday
23.Docusate sodium 100 mg PO BID
24.Fentanyl patch 100 mcg every 72 hours
25.Gabapentin 800 mg PO BID
26.Levothyroxine 50 mcg daily
27.Multivitamin 1 PO Daily
28.Oxybutynin 5 mg PO BID
29.Hydrocodone 5/325 1-2 tablets every 6 hours PRN pain
Allergies:
She is allergic to Cipro, which causes Uticaria and hives,
contrast dye, honey and bee venom, adhesive, and sulfas, which
causes hives
Physical Examination:
Vital signs: 38.6, 120, 20, 138/38, 64% on room air. She is
maintaining O2 sat of 91 to 92 on 4 liters nasal cannula.
Constitutional: She is somnolent. Oriented to person and

6. place. Appears ill and mildly dyspneic.
Head: Normocephalic and atraumatic. Nose: Midline, right
and left maxillary and frontal sinuses are nontender bilaterally.
Oropharynx: Clear and moist. No uvula swelling or exudate
noted.
Eyes: Conjunctivae, EOM and lids are normal. PERL. Right
and left eyes are without drainage or nystagmus. No scleral
icterus.
Neck: Normal range of motion and phonation. Neck is supple.
No JVD. No tracheal deviation present. No thyromegaly or
thyroid nodules. No cervical lymphadenopathy noted
bilaterally.
Cardiovascular: rapid rate, S1 and S2 without murmur or
gallop. Brachial, radial, dorsalis pedis, and posterior tibial are
2+/4+ bilaterally.
Chest: Respirations are regular and even with mild
dyspnea. Lungs are coarse and with some rales in the posterior
bases.
Abdomen: Soft. Bowel sounds are active, nontender, no
masses noted. No hepatosplenomegaly noted. No peritoneal
signs.
Musculoskeletal: Full range of motion of the bilateral
shoulders, wrists, elbows.
Neurologic: Somnolent. Cranial nerves II-XII are intact.
Skin: Warm and dry.
Psychiatric: Mood and affect are normal. Calm and
cooperative. Behavior, judgment is intact.
Laboratories and Diagnostics:
WBC 7.2, Neutrophil 63%
Creatinine 2.0, BUN 45, Na 144, Potassium 4.4
BNP 242
Lactate 1.0
All other labs are unremarkable
Chest x-ray: Right lower lobe infiltrate
EKG: NSR, no ST or T wave changes

7. One hour after your saw Mrs. X, you get a call from the RN to
report that her BP is now 75/40, pulse is 140, RR is 34 and
dyspneic, temperature is 39.6 and she is minimally responsive.
Mrs. X is transferred to the MICU.
Upon re-evaluation of Mrs. X you note that she is obtunded,
struggling to breath, using accessory muscles and O2sats are
85% on a Non-rebreather. She is intubated and placed on a
ventilator. A central line is placed and confirmation obtained
via CXR. A foley is placed and fluid resuscitation has begun.
WBC 20
Hgb 12
HCT 36
Platelets 98,000
Na 148
Chloride 110
Potassium 5.6
Glucose 190
Creatinine 3.0
BUN 68
Albumin 3.0
Anion Gap 21
Lactate 5.2
Procalcitonin 15, INR is 1.0, aPTT 23
ABG (prior to intubation) pH 7.28, PCO2 36, HCO3 17
EKG: Atrial Fibrillation with RVR at 156
CVP 3
Answer the following questions:
30.What are 4 plausible differential diagnoses for Mrs. X’s
hypoxemia that are specific to her clinical scenario? How would
each diagnosis cause a hypoxemia?

8. 31.What is your final diagnosis for the hypoxemia?
32.What are the most likely organisms to cause the diagnoses
you identified in question 2?
33.Upon initial evaluation what category of sepsis was Mrs. X?
34.Upon re-evaluation what category of sepsis was Mrs. X?
35.Why is a gram negative bacteremia more serious than one
caused by a gram positive organism?
36.What is the most likely source of Mrs. X sepsis?
37.What is a CVP and what does a value of 3 indicate? Why is
Mrs. X CVP 3?
38.What is a Procalcitonin and what is its purpose?