Clinical Questions And Answers

Student's Name_______________________________ Date__________________________ Patient's Room Number________________________ Patient's Initial's________________ Diagnosis__________________________________________________________________ __________________________________________________________________________ 1. Describe the pathology related to your patient's medical diagnosis listed above. Include textbook signs and symptoms, and those of your patient which substantiates his diagnosis. Stage IV Decubitus Ulcer/ VRE/MRSA ~ A pressure ulcer is an area of skin that breaks down when you stay in one position for too long without shifting your weight. This often happens if you use a wheelchair or you are bedridden, even for a short period of time (for example, after surgery or an injury). The constant pressure against the skin reduces the blood supply to that area, and the affected tissue dies. A pressure ulcer starts as reddened skin but gets progressively worse, forming a blister, then an open sore, and finally a crater. The most common places for pressure ulcers are over bony prominences (bones close to the skin) like the elbow, heels, hips, ankles, shoulders, back, and the back of the head. Stage I: A reddened area on the skin that, when pressed, is "non-blanchable" (does not turn white). This indicates that a pressure ulcer is starting to develop. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin breakdown now looks like a crater where there is damage to the tissue below the skin. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints. MRSA ~ is caused by a strain of Staphylococcus aureus (S. aureus) bacteria. S. aureus is a common type of bacteria that normally lives on the skin and sometimes in the nasal passages. MRSA refers to S. aureus strains that do not respond to the antibiotics normally used to cure staph infections. The bacteria can cause infection when they enter the body through a cut, sore, catheter, or breathing tube. The infection can be minor and local (for example, a pimple), or more serious (involving the heart, blood, or bone). Serious staph infections are more common in people with weak immune systems. This includes patients in hospitals and long-term care facilities and those receiving kidney dialysis. MRSA infections are grouped into two types: Healthcare-associated MRSA (HA-MRSA) infections occur in people who are or have recently been in the hospital. Those who have been hospitalized or had surgery within the past year are at increased risk. MRSA bacteria are responsible for a large percentage of hospital-acquired staph infections. Community-associated MRSA (CA-MRSA) infections are ones that occur in otherwise healthy people who have not recently been in the hospital. The infections have occurred among athletes who share equipment or personal items (such as towels or razors) and children in daycare facilities. Members of the military and those who get tattoos are also at risk. The number of CA-MRSA cases is increasing. Staph skin infections cause a red, swollen, and painful area on the skin. Other symptoms may include: Drainage of pus or other fluids from the site Fever Skin abscess Warmth around the infected area . Symptoms of a more serious staph infection may include: Chest pain ,Chills ,Fatigue ,Fever ,General ill feeling (malaise) ,Headache ,Muscle aches ,Rash ,Shortness of breath. Vancomycin-resistant enterococci ~ (VRE) infection is the most common type of infection acquired by patients while hospitalized. Patients at risk for VRE are those who are already ill, and hospitalized, including individuals with diabetes, elderly, ICU patients, kidney failure patients, or patients requiring catheters. Enterococci can survive for months in the digestive tract and female genital tract. Other risk factors for acquiring VRE include those how have been previously treated with vancomycin and combinations of other antibiotics. Treatment of VRE is generally with other antibiotics other than vancomycin.. Stroke ~ can happen when the following occurs: A blood vessel that supplies blood to the brain is blocked by a blood clot. This is called an ischemic stroke. A blood vessel breaks open, causing blood to leak into the brain. This is called a hemorrhagic stroke. If blood flow is stopped for longer than a few seconds, the brain cannot get blood and oxygen. Brain cells can die, causing permanent damage. The symptoms of stroke depend on what part of the brain is damaged. In some cases, a person may not even be aware that he or she has had a stroke. Symptoms usually develop suddenly and without warning. They may be episodic (occurring and then stopping) or they may slowly get worse over time. Symptoms may include: Change in alertness (consciousness) ;Coma, Lethargy, Sleepiness, Stupor, Unconsciousness ,Withdrawn .Difficulty speaking or understanding others .Difficulty swallowing .Difficulty writing or reading .Headache ,Occurs when lying flat .Wakes you up from sleep .Gets worse when you change positions or when you bend, strain, or cough .Starts suddenly ,Loss of coordination , Loss of balance , Movement changes, usually on only one side of the body ,Difficulty moving any body part ,Loss of fine motor skills ,Nausea or vomiting ,Seizure ,Sensation changes, usually on only one side of the body ,Decreased sensation ,Numbness or tingling ,Sudden confusion ,Weakness of any body part , Vision changes ,Decreased vision , Loss of all or part of vision. Dementia (End-Stage) ~ Is manifested by patient's who have memory impairment and at least one of the following: language impairment, apraxia (inablity to perform previously learned tasks), agnosia (inability to recognize objects) and impaired executive function (poor abstract thinking, mental flexibility, planning and judgement). Depression is

common in pt's with dementia. Pt's with dementia r/t Alzheimer's typically present with early problems in memory and visuospatial abilities (becoming lost in familiar surroundings, inability to copy simple geometric shapes on paper) Social graces may be retained despite advanced cognitive decline. As the disease progresses personality and behavioral changes may develop. My patient is an 83 y/o female with a history of CVA. She is unable to verbalize, is completely dependent for ADL's, and has end-stage dementia. My patient also has a stage 4 decubitus ulcer on her left lower buttock, it measures 4'L x 3'W x 2'D, and has 1' of tunneling on the superior edge of the wound. A culture and sensitivity test on 4/7/09 found the wound to have VRE and MRSA in small amounts colonizing the wound.

2. Describe your patient's lab work, and relate it to the medical diagnosis above. Be sure to point out how the lab work substantiates the diagnosis. Give norms in parenthesis. Culture & Sensitivity (wound) ~ Colonies of microorganisms are combined with different antibiotics to see how well each antibiotic stops each colony from growing. The test determines the effectiveness of each antibiotic against a particular organism. The test shows which antibiotic drugs should be used to treat an infection. Because many organisms continue to show resistance against various antibiotics, sensitivity tests have become more and more important. If the organism shows drug resistance to the antibiotics used in the test, then those antibiotics will not be effective treatment. Results of pt: Many WBC's , no anaerobes, sparse growth of Proteus mirabilis, sparse growth of Enterobacter cloacae, *Enterococcus faecalis/(VRE) in broth only, *Staphyloccus aureus/(MRSA) in broth only. ~ Pt's culture and sensitivity showed many WBC's indicating infection and showed MRSA and VRE in broth confirming the VRE/MRSA bacteria in the stage 4 decubitus ulcer. General Chemisty ~ The Basic Metabolic Panel (BMP) is a frequently ordered panel of tests that gives your doctor important information about the current status of your kidneys, blood sugar, and electrolyte and acid/base balance. Abnormal results, and especially combinations of abnormal results, can indicate a problem that needs to be addressed. Normal Values: Glucose - 70-90mg/dl Chloride - 95-110mEq/L BUN - 5-25mg/dl CO2 - 23-31mEq/L Creatinine - 0.7-1.5mg/dl Anion Gap - 5-15mEq/L GFR - 60mg/dl Calcium - 8.5-10.5mg/dl Sodium - 135-145mEq/L K+ - 3.5-3mEq/L Results: Glucose: 89mg/dl BUN: 41 HIGH Chloride: 103mEq/L Creatinine: 0.9mg/dl CO2: 24mEq/L

GFR: 56.69 Sodium: 139mEq/L K+: 4.0mEq/L

Anion Gap: 12mEq/L Calcium: 9.6mg/dl

CBC ~ To determine general health status and to screen for and monitor a variety of disorders, such as anemia . Normal Values: WBC: 5.0-10k/ul RBC: 4.2-5.4m/ul HGB: 12.0-14.0gm/dl Hct: 36-48% MCV: 82-98fl MCH: 26-31pcg Platelet: 140-450k/ul Abs Neutr: 4.74 Lymphocyte: 2.4 Monocytes: 0.72 Eosinophil: 0.18 Basophils: 0.08

Patient Values: WBC: 8.1k/ul RBC: 3.47m/ul Low HGB: 10.1gm/dl Low Hct: 32% Low MCV: 92fl MCH: 29pcg Platelet: 453k/ul High Abs Neutr: 3%–6% Lymphocyte: Monocytes: Eosinophil: Basophils:

3. Describe procedures your patient has under gone in reference to the medical diagnosis above. Describe how the results of the procedure ( x-rays, scope, therapy, surgery, etc.) substantiates the diagnosis. My patient had a culture and sensitivity test done on 4-7-2009 of her stage 4 decubitus ulcer on her left buttock, results were found to have MRSA and VRE. Patient was put on contact precautions due to the results of the test. Another culture and sensitivity test was scheduled for 4-16-2009. Patient was in physical

therapy and then put on a maintenance plan to prevent any further contractures, physical therapy was maxed out and they said they could not improve her ROM but could prevent it from becoming worse. She has a foley catheter in place to prevent any further skin breakdown from urine. ROM is performed as tolerated by the patient along with having the patient OOB in a wheelchair as tolerated. She has had a removal of a basal cell carcinoma of her skin on her temple removed and has a small scab where it was removed. She is B12 deficient and is given B12 subq 1000mcg every week. at 0900. My patient is on contact precautions due to the confirmed MRSA and VRE infections of the decubitus ulcer on her left buttock. 4. Describe treatment for your patient. Be sure to include all pertinent medications that are being used in regards to the medical diagnosis listed above, which you may have just described. My patient is on a turn schedule of every two hours to keep pressure off of her pressure points to prevent further decubitus ulcers from forming. She is to only be turned onto her right side and her back with a wedge underneath her back to relieve pressure from the left buttock. My patient also has a pressure relieving air mattress. Her feet are plantar flexed and are to be put in heel floats daily to help position her feet and to prevent ulcerations of the heels. My patient is prescribed 650mg of Tylenol every 4 hours PRN for pain. Wound care for the stage 4 decubitus ulcer includes NS cleansing of the wound to remove debri, acetic acid packing to pack into the wound, and then cover with 6x8in derma cover pad. She is also on contact precautions due to the MRSA and VRE bacteria found upon the results of the culture and sensitivity test performed on 4-7-2009. Patient is on a physical therapy maintenance plan, as they are no longer able to improve her ROM. The maintenance plan includes hand splints to relax the contractures of the hands and are to be worn for up to 12 hours a day. Patient is also to be put into a wheelchair and OOB for two hours or as tolerated. Patient has a completely pureed diet due to dysphagia, and is completely dependent for feeding. She is a DNR and also no artificial nutrition or hydration is to be provided. ROM is done as tolerated by the patient, although she is unable to verbalize any discomfort. A foley catheter is in place to prevent urine from breaking down her skin any further, she is totally incontinent of bowel and is changed as needed. Due to the immobility of my patient she is frequently constipated and is prescribed senokot 1/2 tablet BID at 0900 and 1700 for the constipation. She is also prescribed aspirin 325mg every day, and Imdur 30mg every day for prevention of further CVA's or heart attack. The Imdur may also be being prescribed to help improve the blood flow to her left buttock as it is an indication of the medication to improve blood flow to ischemic areas of tissue. Lasix is prescribed for my patient, 40mg po every day for relieving any edema she may have due to her past CVA. Vitamin B12 is given every week at 1000mcg subq for deficiency of vitamin B12.