Significant Clinical Events

Nursing 235: Adult Health II

Laboratory Analysis Case Scenario

Patient Initials: KH Age: 60

Height: 65 in

Weight: 67.13 kg

HPI

KH presented to the ED with c/o bug bite on L thigh that occurred about 10 days ago that has turned into an abscess “as big as a personal sized watermelon.” Patient also reported urinary burning, frequency, and urgency. The ED, WBC 37,000, glucose 317, bicarbonate 13, anion gap 25, large amount of acetone, HgbA1C 10.3. Patient was admitted to the hospital for evaluation and management of DKA, DVT, abscess, and UTI.

Past Medical/Surgical History:

· Type 2 Diabetes Mellitus

· Previous tobacco use (1/2 pack per day)

· MVA 7/13/20: pain in pelvis and knees since accident

Significant Clinical Events:

8/23/20

· Wound culture: staph aureus, methicillin sensitive

· Blood culture: no growth after 5 days (determined on 8/28/10)

· Urine analysis indicates infection and DKA

· Insulin drip for DKA

· IV antibiotics for UTI, multiple abscesses

· IV antifungals for multiple abscesses & topical antifungal for yeast infection

8/24/20

diffuse myositis & muscle necrosis

· Deep muscle abscess extends to femur (visualized via CT)

· I&D done in OR discovered diffuse myositis & muscle necrosis

· S/p insulin drip for DKA treatment

· Wound nurse consult

· Infectious disease consult

8/26/20

· I&D done in OR on L thigh, R groin abscess

· Patient experience bleeding post-op

· SCD and TED hose prescribed for DVT

8/28/20

· d/c Coumadin due to post procedure bleeding, switched to Lovenox

8/29/20

· bleeding from wound, changed lovenox to heparin

· anemia due to blood loss s/p I&D, received 2 units packed RBC

· Constipation for 1 wk, senna, colace, lactulose

8/30/20

· blood glucose 340-360 mg/dL all day

· patient complains of recent onset visual disturbances (since hospitalization on 8/23/10)

· notify MD, increase levemir to 32 units daily

· MD d/c IV antibiotic and heparin, change to PO antibiotics and coumadin

antibiotic and heparin

Test/Result	Admit 8/23/20	Sun 8/29/20	Mon 8/30/20
Hemoglobin (g/dL)	13.8	7.4L	9.1L
Hematocrit (%)	42.2	21.1L	25.8L
RBC (M/uL)	4.35	2.28L	2.82L
WBC (K/Ul)	37.2H	11.4H	14.2H
MCV (FL)	97.1H	92.5	91.7
MCH (PG)	31.7	32.3	32.3
MCHC (g/dL)	32.7	35	35.2
RDW (%)	15.1H	15.8H	15.5H
PLT (K/uL)	461H	408	428H
MPV (FL)	7.5	6.6	6.3
PT (Sec.)	n/a	9.7	10.0
INR	n/a	0.93	0.96
PTT (Sec.)	n/a	29.4 @ 0600 30.3 @ 1400	24.6 @ 0600 48.1 @ 1400
guaiac			negative
BUN (mg/dL)	15	7L	6L
Creatinine–mg/dl	0.96	0.29L	0.36L
GFR AF	54	n/a	>60
BNP	277H
AGAP	25.0H	8.0	9.0
Chlroide (mmol/L)	92L	102	98
CO2 (mmol/L)	13L	24	25
Potassium (mmol/L)	4.8	4.1	4.0
Sodium (mmol/L)	130L	134L	132L
Glucose (U/L)	397H	266H	368H
HgbA1C	10.3H
Urinalysis Color Yellow	yellow
Appearance Clear	Hazy
Spec. Gravity 1.002-1.030	1.025
PH 4.5-8.0	5.5
Protein Negative	200mg/dL
GLU Normal	1000mg/dL
Ketones Negative	>150
Blood Negative	300
Urobilinogen Normal	2mg/dL
Leuk Ester Negative	500

Dx. Tests Date and Client Results

Gram Stain	8/23/10 & 8/25/10 wound culture: gram positive cocci staph like
Cultures/ Sensitivities	blood culture 8/23/10: no growth after 5 days (8/28/10) wound culture of groin abscess: staph aureus, sensitive to methicillin, clindamycin, erythromycin, oxacillin, naficillin, amoxicillin, clavulanic acid, ampicillin, sulbactam, SXT, most parenteral and oral cephalosporins 8/23/10 urine culture: >100,000 CFU/mL staph aureus sensitive methicillin, nitrofurantoin, oxacillin, SXT 8/25/10 culture abscess L bottom: staph aureus (see above wound culture for sensitivities)
Therapeutic Drug Levels	PT (9-11.5 sec) and INR (2.0-3.0) evaluate therapeutic drug levels of coumadin, PTT (60-70 sec) evaluate therapeutic levels of heparin.

Dx. Tests Date and Client Results

CXR	8/23/10 CXR: cardiac mediastinal silhouettes normal, lungs are clear. No pleural effusion or indication of CHF.
CT/US/ Nuc Med/ Spec Proc	8/26/10 CT abdomen & pelvis without contrast: inflammatory mass-like density with subcutaneous of R groin containing central air bubbles presumably secondary to recent drainage/intervention. No well-organized fluid collection in region. Body wall and intra-abdominal edema. Few non-specific bubbles of air within lower anterior abdominal wall. Abscess in proximal L thigh and L buttock not imaged. 8/26/10 CT pelvis with IV contrast: superficial L medial buttock abscess 5-6cm diameter extending inferiorly and connected to large deep muscle abscess, extends to femur measures 8x10cm
Cardiac monitoring	Measure and compare with report: PR interval: QRS: QT interval: P-P interval regular: R-R interval regular:

Medications

Cefazolin (Ancef) 2g/D5W 110mL IVPB q 8hrs infuse over 30 min

Clindamycin (Cleocin) 900mg IVPB infuse over 30 min

Fluconazole (Diflucan) 100mg PO Q 24hrs

Heparin 100 units/mL standard infusion

Warfarin (Coumadin)

Nystatin Topical

Insulin Aspart 0-14 units SQ 4 times daily ac/hs

Insulin Detemir (Levemir) 32 units SQ daily

Polyethylene glycol (Golytely) 400mL PO one time

Acetaminophen (Tylenol) 650mg PO q 4 hrs prn

Oxycodone (Oxycontin) 5 mg PO Q 4 hrs prn

Morphine (Duramorph) 4mg IV Q 3hrs prn

Hydromorphone (Dilaudid) 1mg IV Q 3hrs prn

Calcium Carbonate (Tums) chewable 500mg PO 3x daily prn

Promethazine (Phenergan) 6.25mg IV q 4hrs prn

Sennosides/ docusate sodium 8.6mg/50mg 1 tablet PO BID prn

Trazadone (Desyrel) 25mg PO hs prn