Nursing help needed:
Ted is a 67-year-old
male with no significant past medical history, except for
occasional migraine headaches. He is married, has two grown
children, and is retired from the Air Force. He does not smoke and
does not use alcohol. He has no regular exercise program but does
try to eat healthy. On June 15, Ted awoke with pain in his chin and
jaw that radiated to his left ear. The next day, he visited his
physician, as the pain had become more intense. He described the
pain as severe, sharp, and constant. His physician could find no
cause for the facial pain, and convinced it was likely a dental
problem, he advised Ted to see his dentist.
Since the pain remained constant with unremitting intensity, Ted
saw his dentist the next day. He was prescribed amoxicillin for a
likely developing dental abscess and was to return in 1 week for
definitive treatment. When he returned to his dentist 1 week later,
the pain had somewhat subsided, but no evidence of a dental abscess
could be found either by x-rays or clinical symptoms.
Over the next two days
Ted was not improved. He continued to have fever, and he described
shooting pains in his face, accompanied by pain in his back and
legs. He was brought to the emergency room by family members for
the fever pain, and dizziness. He was treated for viral syndrome
and discharged with amitriptyline, an antiviral medication,
oxycodone for pain, and meclizine for nausea. Throughout the
following evening, Ted's nausea worsened, the fever increased, and
his mental status declined. His family noticed mild confusion,
particularly with timing of events and short-term memory. He also
developed a rash on his lower legs, both axillae and over his
shoulders. Ted's family brought him back to the emergency
department because of persistent fever, worsening mental status,
and the inability to keep down his food.
Upon this third visit to an emergency department, Ted was found to
be in obvious discomfort, mildly confused, but oriented to person
and place. He had no history of trauma or seizures and demonstrated
no photophobia. He did experience left-sided neck pain. Pupils were
equal and reactive to light. Tympanic membranes were clear
bilaterally, and his oropharynx and nasopharynx were dry without
swelling or drainage. He had slight crackles in the right lung
indicating the presence of fluid, but the left lung was clear.
Neurological exam revealed cranial nerves II-XII were normal.
Sensation was equal bilaterally in upper and lower extremities.
Muscle strength was normal in all extremities. Vital signs were as
follows: temperature 102.8F, pulse 98 bpm, normal heart rhythm,
blood pressure 136/79 mm Hg, respiratory rate 24/min, and weight 96
kg.
Question 1 - There are several signs and symptoms here, but what part of Ted's body do you think should be the focus of further testing?
During the 2 hours in the emergency department, while awaiting laboratory and X-ray results, Ted became more confused, failed to recognize family members, and ceased to follow commands. A computed tomography (CT) scan of the brain was done, which was normal. A lumbar puncture (spinal tap) was performed with the following results: protein 101, glucose 89, nucleated cells 960, segmented neutrophils 78. The cerebrospinal fluid (CSF) was slightly cloudy, but colorless.
Question 2 - Ted is getting worse. Carefully looking at the laboratory tests, what do they suggest?
The attending physician ordered Ted be admitted to intensive care. With the hospital being at high census, Ted was kept in the emergency department for the night awaiting a monitored bed in a respiratory isolation room. He was started on intravenous (IV) normal saline at 150 ml/hr, clear liquids as tolerated, vancomycin 2 grams IV every 12 hours, and metoclopramide 10 mg every 3 hours as needed for nausea. Ted was received in the medical intensive care unit (ICU) the following morning. Upon admission to the ICU, Ted was slowly moving his extremities. He did not open his eyes to voice or pain and did not follow commands or recognize family members. Vital signs were as follows: temperature 102.6 [degrees] F, pulse 116 bpm, respiratory rate 36/min, and blood pressure 118/67 mm Hg. His breathing was rapid, shallow, and labored. An arterial blood gas sample showed his oxygen intake was below normal. He experienced increasing respiratory distress with crackles and wheezing in both lung fields. A repeat chest X ray revealed bilateral pulmonary edema. A pulmonary consult was ordered, and Ted was intubated and placed on mechanical ventilation due to clinical respiratory failure and inability to control his airway. Ted's pulmonary status continued to worsen over the next 3 days, with increased airway pressures, decreased pulmonary compliance, and increased oxygen requirements. His chest X ray, as well as clinical evidence, indicated adult respiratory distress syndrome (ARDS).
Question 3 - What organ system is being affected the most?
Over the next 7 days, Ted remained neurologically unresponsive, mechanically ventilated, and received sedation with lorazepam and morphine to achieve comfort and maintain ventilator synchrony. His mental status did not improve even during short periods of time off sedation. Supportive care consisted of enteral feedings via gastric tube, physical therapy to maintain muscle tone, and fever management. During one of several conversations with the attending nurse, Ted's wife recalled he had a large mosquito bite on his left ear before leaving home 2 weeks earlier. By day 10, Ted had made some improvement and was responsive to voices and able to follow simple commands. On day 11, Ted was sleepy but arousable, and slowly followed commands. Due to improved pulmonary function, the physician ordered Ted be removed from the ventilator. He tolerated it well and maintained appropriate oxygen saturation levels. He denied breathing difficulties.
Question 4 - Ted is getting better. Any new information that gives you a clue as to Ted's diagnosis?
Laboratory Findings
typically seen with Ted's disease:
* Total leukocyte (white blood cell) counts in peripheral blood
were mostly normal or elevated with low lymphocyte counts and
anemia also present.
* Hyponatremia (low blood sodium levels) was sometimes
present.
* CSF showed presence of white blood cells with a predominance of
lymphocytes. Protein was universally elevated. Glucose was
normal.
* CT of brain usually did not show evidence of acute disease, but in about one-third of patients, magnetic resonance imaging (MRI) showed swelling of the brain.
Treatment is
supportive, involving hospitalization, IV fluids, respiratory
support, and prevention of secondary infections for those with
severe disease such as Ted. Potential complications of the disease
include decreased level of consciousness, irritability, muscle
weakness, respiratory complications, immobility, and nutritional
risks. Ted demonstrated all these complications, with the gravest
being markedly decreased level of consciousness and profound
respiratory distress.
Ted's lab results were, for the most part, consistent with these
findings. His white blood cell count (WBC) was normal, but did show
slight lymphocytopenia. However, he was not anemic. The CSF
analysis revealed elevated protein, and normal glucose levels. The
CT of his brain was normal. Signs and symptoms of mild
disease generally last a few days. However, signs and symptoms of
severe disease may last several weeks, and some neurological
effects may be permanent. Children recover faster than adults.
Muscle weakness and pain can persist for an extended period of
time.
Ted suffered severe disease and at the time of this writing, 6
weeks after symptom onset, he still experiences muscle weakness,
restlessness, and slow response times. His family states that when
he is fully awake, his mental status is becoming more normal.
Question 5 -what disease did Ted suffer from?
1.what part of the Ted body should be focused on further testing?
2.what do they suggest?
3.which organ system affected most?
4.New information that give a clue to the diagnosis;
5.DIAGNOSIS;
Nursing help needed: Ted is a 67-year-old male with no significant past medical history, except for...
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