D.R. is a 27-year-old man, who presents to the nurse practitioner at the Family Care Clinic complaining of increasing SOB, wheezing, fatigue, cough, stuffy nose, watery eyes, and postnasal drainage—all of which began four days ago. Three days ago, he began monitoring his peak flow rates several times a day. His peak flow rates have ranged from 65-70% of his regular baseline with nighttime symptoms for 3 nights on the last week and often have been at the lower limit of that range in the morning. Three days ago, he also began to self-treat with frequent albuterol nebulizer therapy. He reports that usually his albuterol inhaler provides him with relief from his asthma symptoms, but this is no longer enough treatment for this asthmatic episode.
Case Study Questions
According to the case study information, how would you classify the severity of D.R. asthma attack?
Name the most common triggers for asthma in any given patients and specify in your answer which ones you consider applied to D.R. on the case study.
Based on your knowledge and your research, please explain the factors that might be the etiology of D.R. being an asthmatic patient.
Fluid, Electrolyte and Acid-Base Homeostasis:
Ms. Brown is a 70-year-old woman with type 2 diabetes mellitus who has been too ill to get out of bed for 2 days. She has had a severe cough and has been unable to eat or drink during this time. On admission, her laboratory values show the following:
Serum glucose 412 mg/dL
Serum sodium (Na+) 156 mEq/L
Serum potassium (K+) 5.6 mEq/L
Serum chloride (Cl–) 115 mEq/L
Arterial blood gases (ABGs): pH 7.30; PaCO2 32 mmHg; PaO2 70 mmHg; HCO3– 20 mEq/L
Case Study Questions
Based on Ms. Brown admission’s laboratory values, could you determine what type of water and electrolyte imbalance does she has?
Describe the signs and symptoms to the different types of water imbalance and described clinical manifestation she might exhibit with the potassium level she has.
In the specific case presented which would be the most appropriate treatment for Ms. Brown and why?
What the ABGs from Ms. Brown indicate regarding her acid-base imbalance?
Based on your readings and your research define and describe Anion Gaps and its clinical significance.
Full Answer Section
Common Asthma Triggers and D.R.'s Potential Triggers:
- Common Triggers:
- Respiratory infections (viral, bacterial)
- Allergens (pollen, dust mites, pet dander)
- Exercise
- Cold air
- Irritants (smoke, strong odors)
- Stress
- D.R.'s Potential Triggers:
- D.R.'s symptoms began with a stuffy nose, watery eyes, and postnasal drainage, strongly suggesting a respiratory infection or allergic rhinitis.
- Since he is having a stuffy nose, and watery eyes, it is possible that seasonal allergies are contributing to his exacerbation.
3. Etiology of D.R.'s Asthma:
- Asthma is a chronic inflammatory disease of the airways.
- Genetic Factors: A family history of asthma or allergies increases the risk.
- Environmental Factors:
- Exposure to allergens and irritants during childhood can contribute to asthma development.
- Respiratory infections, especially in early life, can also play a role.
- Hygiene hypothesis: some research suggests that a lack of early childhood exposure to certain infections or bacteria can increase the risk of asthma.
- Immune System Dysregulation:
- In asthma, the immune system overreacts to triggers, leading to airway inflammation and bronchoconstriction.
Ms. Brown's Case:
1. Water and Electrolyte Imbalance:
- Ms. Brown has hypernatremia (high sodium), hyperglycemia (high glucose), and hyperkalemia (high potassium).
- She also has a mild metabolic acidosis.
- The high sodium indicates a relative deficit of water in relation to sodium, suggesting dehydration. The high glucose is due to her uncontrolled diabetes.
- The elevated potassium is a concern, and often occurs with dehydration, and uncontrolled diabetes.
2. Signs, Symptoms, and Clinical Manifestations:
- Hypernatremia (Dehydration):
- Thirst
- Dry mucous membranes
- Decreased skin turgor
- Confusion, lethargy, or coma (in severe cases)
- Hyperkalemia:
- Muscle weakness
- Cardiac arrhythmias (potentially life-threatening)
- Nausea, vomiting
- Ms. Brown's potassium level of 5.6 mEq/L is moderately elevated and requires close monitoring due to the risk of cardiac complications.
- Hyperglycemia:
- Increased thirst
- Increased urination
- Blurred vision
- Fatigue.
3. Most Appropriate Treatment:
- The most appropriate treatment is rehydration with intravenous fluids, insulin therapy to control her hyperglycemia, and monitoring of her potassium levels.
- Rehydration is crucial to address the hypernatremia and dehydration.
- Insulin will help lower her blood glucose and also help drive potassium back into the cells.
- Because of the elevated potassium, cardiac monitoring is very important.
- Careful monitoring of her electrolyte levels is also critical.
- It is important to rehydrate her slowly, to avoid cerebral edema.
4. ABG Interpretation:
- Ms. Brown's ABGs indicate metabolic acidosis with partial respiratory compensation.
- pH: 7.30 (acidic)
- PaCO2: 32 mmHg (low, indicating respiratory compensation)
- HCO3–: 20 mEq/L (low, indicating metabolic acidosis)
- The low PaCO2 is her body's attempt to compensate for the acidosis by blowing off carbon dioxide.
- The low PaO2 indicates hypoxemia, which is likely due to her respiratory infection.
5. Anion Gap:
- Definition: The anion gap is the difference between the measured cations (positively charged ions) and anions (negatively charged ions) in the serum. It is calculated as: Anion Gap = (Na+ + K+) - (Cl– + HCO3–).
- Clinical Significance:
- It helps differentiate the causes of metabolic acidosis.
- A normal anion gap suggests a loss of bicarbonate (e.g., diarrhea, renal tubular acidosis).
- An elevated anion gap suggests an increase in unmeasured anions (e.g., lactic acidosis, ketoacidosis, renal failure).
- In Ms. Browns case, we would expect to see an elevated anion gap, due to the ketoacidosis caused by her uncontrolled diabetes.
- The anion gap is a valuable tool for assessing the severity and cause of metabolic acidosis.