Musculoskeletal: Full range of motion of the bilateral shoulders, wrists, elbows.

Neurologic: Somnolent. Cranial nerves II-XII are intact.

Skin: Warm and dry.

Psychiatric: Mood and affect are normal. Calm and cooperative. Behavior, judgment is intact.

LABORATORIES AND DIAGNOSTICS:

• WBC 7.2, Neutrophil 63%
• Creatinine 2.5 mg/dL, BUN 45 mg/dL, Na 144 mEq/L, Potassium 4.4 mEq/L, Total Bilirubin is 0.9 mg/dL, Platelets 100,000
• BNP 242 pg/mL
• Lactate 1.0 mg/dL
• All other labs are unremarkable
• Chest x-ray: Right lower lobe infiltrate
• EKG: NSR, no ST or T wave changes

One hour after you saw Mrs. X, you get a call from the RN to report that her BP is 75/40 mmHg, heart rate is 140, respiratory rate is 34 and she is dyspneic. Her temperature is 39.6 and she is minimally responsive.  Upon re-evaluation of Mrs. X you note that she is obtunded, struggling to breath, using accessory muscles and O2sats are 85% on a Non-rebreather. Repeat labs are as follows:

WBC 20,000

Hgb 12 g/dL

HCT 36%

Platelets 98,000

Na 148 mEq/L

Chloride 110 mEq/L

Potassium 5.6 mEq/L

Glucose 190 mg/dL

Creatinine 3.0 mg/dL

BUN 68 mg/dL

Albumin 3.0 g/dL

Anion Gap 21

Lactate 5.2 mg/dL

Procalcitonin 15 ng/dL, INR is 1.0

aPTT 23 seconds

EKG: Atrial Fibrillation with RVR at 156

Questions:

1. What is the most likely cause of her atrial fibrillation with RVR and her pulmonary decompensation?
2. Based on the available clinical data, list all the acute diagnoses. There is a total of 8. Some may be repeated from last week.
3. What additional diagnostic tests should be ordered to further evaluate her cardiopulmonary problems?
4. Write an assessment and treatment plan for the new cardiac diagnosis, new pulmonary diagnosis, and the electrolyte imbalance. Write a treatment plan which addresses nutrition, stress ulcer and DVT prevention. You should have a complete treatment plan for each disorder. All written orders must have complete instructions. For instance, a medication order must have the name, dose, frequency, and route. Lab orders must include the lab name and frequency. If an order should be done now, stat, urgent or routine that also should be indicated.
5. What is the most appropriate level of care for this patient?
6. What physician specialty or other interprofessional consults should be ordered?
7. What anticipatory guidance/patient education should you provide to the patient?