MSN 5041: Adult Gerontology Advanced Critical Care Concepts for Intensivist

A 67-year-old African American 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


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 that 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.


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 acting “strangely” at approximately 8pm the night before admission. This morning


he was confused about the day and year, and forgot many of the details of his daughter’s recent


wedding. She was concerned so she took him to the primary care office, where the NP called


911. She reports there is no recent history of trauma, falls, 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: HTN, DM, Type II, High cholesterol


Past Surgical History: Per wife and the EMR, patient has never had surgery


Social History: Patient’s wife reports he has never smoked, does not drink, does not use drugs




• No known allergies


• Lipitor 10mg PO daily


• Metformin 500mg PO BID


• Per EMR: He is prescribed Amlodipine 10mg PO daily and Toprol 50mg PO daily, but


has not filled his prescriptions for the last 6 months


General Survey The patient’s vital signs on admission to the ER are:


BP 228/116 mmHg


HR: 78 beats per minute, normal sinus rhythm on the monitor


RR: 18 breaths/min


O2 sats: 96% on room air


He is lethargic but easily arousable, disoriented to time and place, and therefore unable to give a


reliable history. Data is gathered from his wife and the electronic medical record (EMR).


Review of Systems


The patient is unable to answer all of the questions; some of the information is obtained from the


patient’s wife.


Constitutional: denies fever, chills


Cardiovascular: denies chest pain, chest pressure, SOB, palpitations


Pulmonary: denies SIB


GI: denies abdominal discomfort, unable to determine last bowel movement


GU: denies burning with urination


Musculoskeletal: denies pain of extremities


Neurological: the patient is unable to provide a timeline as to the onset of confusion; per wife the


patient started acting “strangely” after dinner – “quiet, non-communicative, not answering


questions – said he did not 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 changes to short – and -long term memory.


Endocrine: denies thirst, excessive urination or excessive hunger, does not check blood glucose


at home.


Physical Examination


Vital signs


Repeat blood pressure is 200/120 mmHg in both right and left arms


Temp 36.0 C oral


HR 78 beats per minute


RR 16 breaths per minute


O2 sats 95% on room air


Weight 90 kg


Height 5’10”


BMI 28.1


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”.


HEENT: Normocephalic, anicteric, fundoscopic examination reveals exudates and cotton wool


spots, consistent with grade III retinopathy, no carotid bruits, no thyromegaly, or thyroid




Cardiovascular: S1, S2, no murmurs, no gallops, no rubs, +displaced PMI. Pulses are present


bilaterally +2+2 right and left dorsalis pedis and posterior tibial pulses.


Pulmonary: Respirations are even and unlabored, breath sounds are clear and equal throughout.


Gastrointestinal: Normoactive bowel sounds, abdomen is soft, non-tender, non-distended, no


hepatosplenomegaly, + left epigastric abdominal bruit – systolic diastolic bruit.


Skin: Warm and dry, no rashes or lesions noted.


Musculoskeletal: Nontender spine; +systolic-diastolic bruit – located at the mid to lower left of


the spine.


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 non-focal, able to move


both arms and legs; no facial asymmetry, no dysarthria.


Preliminary Diagnostic Results


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.


CXR demonstrates borderline cardiac enlargement; negative for a widened mediastinum.


NECT: negative for bleeding; diffuse white matter changes consistent with cerebral




Laboratory Results


Today One Year Ago Troponin 0.01 mg/mL


Na 140 mEq/L 136


K 4.4 mEq/L 4.2


Cl 105 mEq/L 107


CO2 24 mEq/L 21


Total cholesterol 200 mg/dL 261


LDL 139 mg/dL 156


HDL 32 mg/dL 25


Triglycerides 300 mg/dL 402


BUN 40 mg/dL 23


Creatinine 2.5 mg/dL 1.0


WBC 6,900 cells/uL 7,600


Hbg 12.7 g/dL 13.8


Hct 35.5% 38.5


Glucose 92mg/dL 105


HgbA1c 8.5 7.0


GFR 36 cc/min 87


Urinalysis: specific gravity 1.020, pH 5.0, color clear, protein 100 mg/dL,


leukocyte esterase negative, nitrate negative, ketones negative, red blood cells




Toxicology screen: negative


Case Study Questions


1. What are the pertinent positive of this case?


2. What are the significant negatives of this case?


3. What laboratory and diagnostic testing should be ordered? Use national guidelines to support


your responses.


4. Provide a case analysis and formulate your diagnosis and treatment plan. Provide a minimum


of 3 differential diagnoses and explain each. Use national guidelines to support your responses.


5. Follow APA, 7th edition guidelines.


(USA, AUS, UK & CA PhD. Writers)


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