CASE #1: Mr. Edward Dunn Adapted from

CASE #1: Mr. Edward Dunn Adapted from NURS 7054 Advanced Pathophysiology II, University of Utah College of Nursing Mr. Dunn is a 52-year-old male with chronic liver disease who has been admitted to the Emergency Department. He was transported by ambulance from the downtown homeless shelter to the hospital after the shelter staff found him on the floor, very confused and lethargic. His friend, who followed the ambulance to the emergency room today, states that Mr. Dunn has been ‘getting worse over the past few weeks’ and that he was having a harder and harder time breathing. His friend states that he takes his medications on and off but continues to drink alcohol daily. His friend states that Mr. Dunn had been vomiting and coughing up blood in the last couple days. Past Medical History Anxiety Disorder Past IV drug use Alcohol abuse Currently Prescribed Medications Lactulose 30 mL PO 3-4 times daily hold for more than 3 soft stools daily Lasix 80 mg po daily Spironolactone 200 mg po daily Physical Examination VITAL SIGNS: Temperature = 38.0, Pulse (P) = 122, Respiratory rate (RR) = 32, Blood pressure (BP) = 88/47, Oxygen saturation (O2 sat) = 88% on 3 L o2 (RA), pain 1/10, Weight (Wt) = 70 kg., Height (Ht) = 167.6 cm GENERAL: Only responsive to pain. Poor hygiene and dentation, confused and flipping around in bed. Coughs at times bringing up moderate amounts of blood. Fast shallow breaths. Systemic jaundice. HENT: sclerra are yellow, PERLA NECK: Jugular vein distention (JVD) up to mandible when sitting at 45 degrees, no bruits, large distended neck veins CARDIAC: Tachycardia regular, S1 and S2 noted, without noticeable murmur, or rub LUNGS: Clear upper left and right lung lobes, decreased right middle lobe, lower lobe, and left lower lobe. Use of accessory muscles, retractions. ABDOMEN: Firm, non-tender, extremely distended, bowel sounds present EXTREMITIES: Positive asterixis in bilateral upper extremities. 2+ palpable pulses, 1+ generalized edema Labs: CBC: WBC 13,000, Hgb 6.7, Plts 87 INR 3.1 CMP: Na 138, K+ 3.9, Cl 106, CO2 28, Creatinine 1.4, BUN 23, Ca 9.0 CD4 count 400 Pre Albumin 6.9 (Normal 15.0 to 35.0 mg per dL) ECG: Sinus tachycardia QUESTIONS How is Mr. Dunn’s distended abdomen related to his chronic liver disease? Group of answer choices A) Scarred liver tissue has lead to portal hypertension and ascites B) Decreased production of clotting factors has led to occult abdominal bleeding (C) Decreased production of complement proteins has lead to increased inflammation, which is most obvious in the peritoneal cavity D) Decreased ability to make urea has lead to an increase in circulating ammonia 2. How does his confusion relate to his chronic liver disease? Group of answer choices A) Decreased ability to make urea has lead to an increase in circulating ammonia B) Decreased production of complement proteins has lead to increased inflammation C) Decreased production of clotting factors has led to bleeding in the brain D) Scarred liver tissue has lead to portal hypertension and ascites 3. Why is Mr. Dunn dyspneic and hypoxemic? (Select all that apply.) Group of answer choices A) Decreased ability to make albumin has lead to decreased oncotic pressure and pulmonary edema B) Decreased production of complement proteins has lead to increased inflammation C) Scarred liver tissue has lead to portal hypertension and ascites, which increases abdominal pressure and decreases the diaphragm’s ability to move downward and increase thoracic expansion D) Decreased production of clotting factors has led to bleeding in the thorax E) Decreased ability to make urea has lead to an increase in circulating ammonia 4. Why does Mr. Dunn have peripheral edema and how is this related to his chronic liver disease? What clinical evidence supports this hypothesis? CASE #2: Dr. Leticia McDonald Dr. McDonald is a 62-year-old female. She presents for her annual checkup and renewal of her SSRI prescription (fluoxetine 20mg daily) for her mild depression (PHQ9 score = 8). Additionally, she reports that her younger sister recently suffered a fracture to her wrist, which has made Dr. McDonald concerned about her own bone density. She would like to discuss the possibility of getting a DEXA scan for herself. QUESTIONS 5. What is the mechanism of action of SSRI medications? 6. Why are post-menopausal women at high risk for osteoporosis? Group of answer choices A) decreased estrogen levels lead to increased osteoclast activity B) decreased estrogen levels lead to increased osteoblast activity C) decreased estrogen levels lead to increased osteocyte activity D) decreased estrogen levels lead to decreased absorption of calcium and phosphate from the gut CASE #3: Mr. Alex Turner Adapted from NURS 7054 Advanced Pathophysiology II, University of Utah College of Nursing Alex Turner, 47-year-old male presents to the Emergency department with a variety of presenting symptoms. He reports that he was diagnosed with type 2 diabetes mellitus two years ago. However, he lost insurance coverage when his company went out of business during the pandemic, and he has not followed up with recommendations for care nor sought medical care for his condition. Fasting glucose level is 198 mg/dL and HbA1c is 9.4%. The following is a list of Mr. Turner’s chief complaints, which you obtained during the admitting process: His leg muscles feel very weak and he is unable to dorsiflex his left foot. Both feet have felt numb for the past 6 months. He stepped on a nail a month ago and the wound has not healed. He noticed that the skin around the wound was swollen and red. He has experienced occasional episodes of chest pain when he climbs stairs. He is thirsty and reports urinating frequently. 7. How is Mr. Turner’s muscle weakness and foot numbness related to his diabetes? ANSWER CHOICES A) The hyperglycemia has impaired perfusion to his peripheral nerves resulting in neuropathy in both sensory and motor nerves. B) Since his fasting blood glucose level is < 200 mg/dL, he is not diabetic, and his muscle weakness and foot numbness must have a different explanation. C) The hyperinsulinemia has caused him to have multiple strokes. As commonly occurs, two of them happened at precisely same region of the sensory cortex on opposite sides of the brain. D) The hyperglycemia has lead to decreased kidney function, which resulted in increased ammonia and encephalopathy. 8. How is Mr. Turner's muscle weakness and foot numbness related to his diabetes? Group of answer choices A) The hyperglycemia has impaired perfusion to his peripheral nerves resulting in neuropathy in both sensory and motor nerves. B) Since his fasting blood glucose level is < 200 mg/dL, he is not diabetic, and his muscle weakness and foot numbness must have a different explanation. C) The hyperinsulinemia has caused him to have multiple strokes. As commonly occurs, two of them happened at precisely same region of the sensory cortex on opposite sides of the brain. D) The hyperglycemia has lead to decreased kidney function, which resulted in increased ammonia and encephalopathy. 9. In what way may the patient's chest pain be related to his diabetes? 10. How is the patient's polyuria and polydipsia related to his hyperglycemia? SCIENCE HEALTH SCIENCE NURSING NUR 684

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