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MSN5040: Adult Gerontology Advanced Critical Care Concepts for Intensivist in Acute Care I
Case Study #1
Case Presentation: Chief Complaint
A 67-year-old male is transported via ambulance from a primary care clinic to the nearest
emergency room (ER) with a severely elevated blood pressure of 228/120 mmHg accompanied
by confusion.
The emergency medical responders report that the patient has a long-standing history of
uncontrolled hypertension (HTN), type 2 diabetes mellitus (DM), and hypercholesterolemia. He
was seen by his primary care nurse practitioner (NP) who noted the patient had an elevated blood
pressure of 230/120 associated with acute confusion. An ambulance was called to transport the
patient to the nearest ER.
General Survey
The patient’s vital signs, on admission to the ER are: blood pressure 228/116 mm Hg, heart
rate 78 beats per minute (bpm), normal sinus rhythm on the monitor, a respiratory rate of 18/
min, and a room air oxygen saturation of 96%. He is lethargic but easily arousable,
disoriented to time and place and therefore unable to give a reliable history. Further data will
be gathered from his wife and electronic medical record (EMR).
History of Present Illness
The patient’s wife denies that the patient experienced weakness, paresis, or paralysis of
extremities, dysarthria, aphasia, or other signs that may indicate a stroke, but notes that the
patient started crying “strangely” at approximately 8pm the night before admission. This
morning, he was confused about the day and year, and forgot many of the details about his
daughter’s recent wedding. She was concerned so took him by taxi to the primary care office,
where the NP called 911. She reports there is no recent history of falls or trauma, or
substance abuse. She endorses that the patient has hypertension and diabetes, as reported by
the primary NP, and denies any history of cancer or heart disease. She also reports that he
stopped taking his blood pressure medications approximately 6 months ago because they
caused excessive fatigue. She is unsure if he is taking his other prescribed medications.
Past Medical History
o Hypertension
o Diabetes
o High cholesterol
Past Surgical History
o Per wife and EMR the patient has never had surgery
Social History
o Patient’s wife reports that he has never smoked, does not drink, does not use drugs
Medications
o Allergies: NKDA
o Lipitor 10mg PO daily
o Metformin 500mg PO BID
o Per EMR: he is prescribed amlodipine, a calcium channel blocker, 10mg by mouth
daily and Toprol, a selective beta-blocker, 50mg by mouth daily, but has not filled his
prescriptions for the last 6 months
Review of Systems
o Constitutional: Denies fevers or chills
o Cardiovascular: Denies chest pain, chest pressure, shortness of breath, palpitations.
o Pulmonary: Denies shortness of breath
o Gastrointestinal: Denies abdominal discomfort; unable to determine last bowel
movement
o Musculoskeletal: Denies pain of extremities
o Neurological: The patient is not able to provide a timeline as to the onset of
confusion; per wife, the patient started acting strangely after dinner – “quiet,
noncommunicative, not answering questions – said he didn’t feel well, but would not
elaborate.” This morning, his wife was concerned when he appeared dazed and
confused. He was disoriented to day and time. Wife reports acute change in shortand long-term memory
o Endocrine: Denies thirst, excessive urination, or excessive hunger, does not check
blood glucose at home
Physical Exam
o Vital Signs: BP 200/120 mmHg in both right and left arms; HR 78 beats per minute;
RR: 16 breaths per minute; O2 saturation on room air is 95%
o Weight: 90 kg; height 5’10”, body mass index (BMI) is 28.1
o Fingerstick: glucose is 92
o Constitutional: Obese male, appears stated age, lethargic, disoriented to time and
place, oriented to person, arouses easily, able to answer simple questions with a “yes”
or “no”
o HEENT: Normocephalic, atraumatic, anicteric, fundoscopic examination reveals
exudates and cotton wool spots consistent with grade III retinopathy, no carotid bruits,
no thyromegaly or thyroid nodules
o Cardiovascular: S1, S2, no murmurs, no gallops, no rubs, +2/+2 right and left dorsalis
pedis and posterior tibial pulses
o Pulmonary: Respirations even and unlabored, breath sounds are clear, equal
throughout
o Gastrointestinal: Normoactive bowel sounds, abdomen is soft, non-tender, no
hepatosplenomegaly, + left epigastric abdominal bruit – systolic-diastolic bruit
o Musculoskeletal: Nontender spine; +systolic-diastolic bruit – located at the mid to
lower left of the spine
o Neurological: Limited neurological examination due to the patient’s inability to
follow commands.
Cranial nerves II-XII intact, however, unable to examine
extraocular movements due to the patient being unable to follow commands;
otherwise grossly nonfocal, able to move both arms and legs; no facial asymmetry, no
dysarthria
Preliminary Diagnostic Results
o 12-lead ECG reveals NSR of 78 beats per minute; PR interval 0.14, QRS interval
0.06; QT interval 0.40 with left ventricular hypertrophy
o CXR demonstrates borderline cardiac enlargement; negative for a widened
mediastinum
o NECT: Negative for bleeding; diffuse white matter changes consistent with cerebral
encephalopathy
Laboratory Results
Today
One Year Ago
Troponin 0.01 ng/mL
Na 140 mEq/L
Na 136 mEq/L
K 4.4 mEq/L
K 4.2 mEq/L
Cl 105 mEq/L
Cl 107 mEq/L
CO2 24 mEq/L
CO2 21 mEq/L
Total cholesterol 200 mg/dL
Total cholesterol 261 mg/dL
LDL 139 mg/dL
LDL 156 mg/dL
HDL 32 mg/dL
HDL 25 mg/dL
Triglycerides 300 mg/dL
Triglycerides 402 mg/dL
BUN 40 mg/dL
BUN 23 mg/dL
Creatinine 2.5 mg/dL
Creatinine 1.0 mg/dL
WBC 6,900 cells/uL
WBC 7,600 cells/uL
Hgb 12.7 g/dL
Hgb 13.8 g/dL
Hct 35.5%
Hct 38.5%
Glucose 92 mg/dL
Glucose 105 mg/dL
HgbA1c 8.5
HgbA1c 7.0
Glomerular filtration rate (GFR) = 36 cc/min
Glomerular filtration rate (GFR) = 87 cc/min
Urinalysis (today):
o Specific gravity: 1.020
o pH 5.0
o Color: clear
o Protein 100 mg/dL
o Leukocyte esterase: negative
o Nitrite: negative
o Ketones: negative
o Red blood cells: negative
Toxicology screen
o Negative
Case Study Questions
1.What are the pertinent positives of this case?
2.What are the significant negatives of this case?
3. Are there any additional labs / diagnostic testing you would consider? If so, why?
4. Based on the patient’s symptoms and lab results, what is your primary diagnosis and why?
5. What national guidelines were used to complete this case study?
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Diabetic Patient Case Study
Name
Institution
Course
Professor
Date
2
Diabetic Patient Case Study
Pertinent Positives and Negatives
Table 1
Pertinent Positives and Negatives
Items
Positives
Negatives
Clinical history and interview
‘stomach virus’ with vomit
No fever, falls, or trauma
worsened in last 24 hours
No history of cardiovascular
History of type 1 diabetes
diseases
Nausea, vomiting, abdominal
No coughing
pain in the last 72 hours
No blood in urine, changes in
Weakness and tiredness
smell, and amount/frequency
History of depression, well
No headache, or history of
managed
seizures
Insulin pump broke down six
No acute psychiatric issues
months ago, manages diabetes
and no suicidal ideation
with injections before bed and
meals
Physical exam
Tachycardia, hypotension,
No cardiovascular symptoms
tachypnea
Lungs are clear, no coughing
Patient appears thin and
or wheezing
slightly older than the stated
No rash, lesions, or ulcerations
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age
Patient is responsive and can
Hyperactive bowel sounds and
shake head to answer yes or
tympanic
no
NIPPV mask
Lethargic and altered mental
status
Laboratory results
High lymphocytes count
Normal hemoglobin and
Low serum CO2
hematocrit
High BUN
Normal platelet count
High creatinine and
Normal PaO2
phosphorus
High blood glucose
pH is lower than normal range
Low PaCO2 and HCO3
High lactic acid levels
Ketones in urinalysis
Diagnoses
Primary Diagnosis
The primary diagnosis for this patient is diabetic ketoacidosis. This is a medical
emergency defined as random blood glucose of more than 250 mg/dl, blood pH of less than 7.3,
and presence of ketones in urine (Dhatariya, 2019). This patient has a blood glucose of 405
mg/dl, pH of 7.13, and urinalysis is positive for ketones. The low serum CO2 also confirms the
diagnosis. Vomiting and nausea can also occur in patients with diabetic ketoacidosis due to
4
metabolic decompensation (Dhatariya, 2019). From the history, the patient has suboptimal
management of her diabetes. Her boyfriend states that he has not seen her inject insulin as usual
and this presents a risk of poor insulin delivery and diabetes management in the patient. This is
the main reason for diabetic ketoacidosis due to lack of adequate insulin delivery to the body.
Differential Diagnoses
Gastroenteritis
Diabetic ketoacidosis, common in people with type 1 diabetes, is often triggered by an
infection. The patient is reported to have had ‘stomach flu’ for the past 72 hours which has been
associated with nausea and vomiting and occasional diarrhea. These symptoms developed before
the changes in breathing, blood glucose, and mental state alteration. Gastroenteritis is an acute
infection lasting a few days and causes abdominal pain, nausea and vomiting, and diarrhea (Chen
et al., 2021). Being one of the most common gastrointestinal infections, it is the most likely to
have affected the patient. Elevated lymphocytes levels indicate possible infection in the patient
(Chen et al., 2021). However, the patient does not present with fever and denies history of fever.
Sepsis
The patient presents with altered mental state and acidosis. Metabolic acidosis is often
seen in patients with severe sepsis. Sepsis develops secondary to an infection which may trigger
the maladaptive body response. In the patient in the case study, the changes in metabolic panel
indicate presence of acidosis. History of abdominal pain with nausea and vomiting indicates
possible infection in the last 72 hours. Consequently, these diagnoses could lead to severe sepsis
which also affects the regulation of blood glucose and levels of CO2 in the blood (Jarczak et al.,
2021). Acidosis in this patient is determined but further assessment is needed to determine the
presence of sepsis or other conditions.
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Elevated BUN and Creatinine Levels
Elevated BUN and creatinine levels indicate presence of Rhabdomyolysis and potential
acute kidney failure. High BUN indicates that the kidneys are not functioning optimally and
hence allowing excess urea to pass through. Similarly, creatinine is filtered by kidneys and when
it is excessive in the blood, it indicates poor kidney function, indicating acute kidney failure
(Kellum et al., 2021). Rhabdomyolysis can occur in diabetic ketoacidosis due to reversible acute
kidney injury. Rhabdomyolysis increases the risk of mortality and irreversible kidney injury in
the patient.
Additional Diagnostic Testing
•
Glomerular Filtration Rate
An additional test that should be ordered is glomerular filtration rate (GFR) test. This test is
necessary in patients suspected of kidney injury or disease. It will determine the efficiency of
kidneys’ extent of kidney injury, and need for treatment (Kellum et al., 2021). GFR is calculated
using patient age, gender, race, height, and weight.
•
Stool Culture Test
The patient presents with abdominal pain and nausea with occasional diarrhea. Stool test can be
used to identify any pathogens to develop an appropriate diagnosis for gastrointestinal symptoms
(Chen et al., 2021). This test is necessary to identify the pathogen causing abdominal pain and
nausea and vomiting. These tests are in addition to blood glucose tests and already completed
laboratory and metabolic profile.
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References
Chen, P. H., Anderson, L., Zhang, K., & Weiss, G. A. (2021). Eosinophilic gastritis/
gastroenteritis. Current Gastroenterology Reports, 23, 1-13.
https://doi.org/10.1007/s11894-021-00809-2
Dhatariya, K. K. (2019). Defining and characterising diabetic ketoacidosis in adults. Diabetes
Research and Clinical Practice, 155, 107797.
https://doi.org/10.1016/j.diabres.2019.107797
Jarczak, D., Kluge, S., & Nierhaus, A. (2021). Sepsis—pathophysiology and therapeutic
concepts. Frontiers in Medicine, 8, 609. https://doi.org/10.3389/fmed.2021.628302
Kellum, J. A., Romagnani, P., Ashuntantang, G., Ronco, C., Zarbock, A., & Anders, H. J.
(2021). Acute kidney injury. Nature Reviews Disease Primers, 7(1), 52.
https://doi.org/10.1038/s41572-021-00284-z
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