MSN5031: Differential Diagnosis and Collaborative Management in Acute Care

CASE STUDY #2

Chief Complaint

Ms. A. is a 45-year-old African American female with history of hypertension, hyperlipidemia,

and end-stage renal disease (ESRD) managed with hemodialysis three times per week who now

presents to the emergency department with complaint of “feeling very tired” and having a low

blood pressure after dialysis.

General Survey and History of Present Illness (HPI)

Ms. A has been an outpatient hemodialysis patient for 2 years due to a history of uncontrolled

hypertension and today received her usual hemodialysis without complications during the

treatment, but toward the end of the dialysis, and following completion, she complained of

feeling exceptionally tired and weak. She had a total of 1000 mL of fluid removed, which was a

usual amount removed during previous dialysis treatments.

Her BP at the end of dialysis was 70/50 mmHg and she was given a fluid bolus of 500 mL of

normal saline that increased her BP to 92/48 mmHg. She continued to complain of severe

fatigue following the fluid bolus and so she was sent from the outpatient unit to the emergency

department (ED).

The AG-ACNP was called to the ED to evaluate the patient. Upon the nurse practitioner’s

arrival, the bedside survey reveals an obese, well-developed, well-groomed, and very pleasant

woman in no acute distress. She is semi-recumbent in bed and is awake, alert, and oriented to

person, place, and time. Her speech is clear and she is appropriate in her responses. She is

moving all extremities. The patient is asked about her baseline blood pressure and stated is

ranged from the 130 to 140/80s. She states, “I forgot to take my medication yesterday so my

blood pressure was very high when I woke up this morning. It was 160/95 and that is high for

me. I took two of my lisinopril tablets because my dialysis wasn’t scheduled until 6pm. I

planned to take my other pressure pill, amlodipine after dialysis if my pressure was still high.”

She went on to say, “I hate when my pressure gets high, because I don’t want to have a stroke

like my mother did.”

The patient verbalizes feeling very faint, nauseous, and diaphoretic towards the end, and

following, her dialysis treatment but completed the whole cycle. She received intravenous fluids

as noted, and felt somewhat better following the infusion but was still no her “usual self”. The

nephrologist at dialysis recommended that she go to the emergency for further evaluation. She

stated she is usually a bit tired after dialysis but has never felt so weak in the past.

The nurse at the dialysis unit calls the ED to report a post-dialysis hemoglobin and hematocrit of

7 g/dL and 23%, respectively. On review of the electronic medical record, the nurse practitioner

learns that one week ago her hemoglobin and hematocrit were 9 g/dL and 27% respectively, and

that these values are at baseline for this patient.

Past Medical History

o Hypertension

o End-stage renal disease

o Obesity

o Chronic anemia

o Denies any history of heart disease

Allergies

No known drug allergies

Family and Social History

o Nonsmoker, lifetime

o No alcohol or illicit substance use

o Father and siblings alive and well, mother with a cardiovascular accident at age 65

Medications

o Amlodipine 10mg daily

o Lisinopril 40mg daily

o Rosuvastatin 10mg daily

o Alprazolam 0.5mg three times a day as needed

Review of Systems (ROS)

The patient is a reliable source for health history.

• Constitutional: Denies recent fever, infection, sleep disorder, and any evidence of active

bleeding. Her appetite has been good and she states she eats a well-balanced diet.

• Head/eyes/ears/neck/throat: Denies headache, earache, drainage from ears or nose,

nosebleeds, or bleeding gums.

• Cardiovascular: Denies chest pain, rapid or irregular heart rate, lower extremity edema,

paroxysmal nocturnal dyspnea, or shortness of breath while lying flat.

• Pulmonary: Shortness of breath when climbing stairs or walking fast and denies cough.

• Gastrointestinal: Denies nausea, vomiting, constipation, or diarrhea and denies bloody or

dark stools. Endorses that she has previously been prescribed iron supplements but

stopped taking the iron recently due to constipation. She states she now has regular

bowel movements.

• Genitourinary: Denies urinary frequency, dysuria, hematuria, or abnormal odor.

• Integumentary: Denies skin rashes, bruising, recent bug bites.

• Musculoskeletal: Denies joint pain, no history of fractures, recent trauma or falls.

• Neurological: Denies headache, dizziness, falls; history of stroke, seizure disorder,

numbness, tingling, or weakness (except for the fatigue and weakness experienced

today).

• Endocrine: denies increased hunger, thirst, urinary frequency and endorses she has

eliminated simple sugars from diet.

• Lymph: Denies any swollen or sore glands.

Physical Examination

Vital signs:

HR 74 bpm BP 92/48 mmHg supine, 100/50 sitting, 95/50 standing Temp 36.4 C

(tympanic). Weight 165 lbs BMI 30 kg/m2 O2 sats 100% on RA

Constitutional: Patient appears well and her stated age. She is calm and maintains eye contact during

provider-patient interaction.

Neurological: no focal neurological deficits, awake, alert, oriented to person, place, and time.

HEENT: pupils are equal, round, reactive to light, buccal mucosa pale pink, moist, neck is supple, no JVD,

oropharynx is moist and rises symmetrically.

Cardiovascular: heart rate and rhythm is regular, normal S1, S2, no murmurs, gallops, rubs, or clicks.

Skin warm, mail beds are pale, capillary refill brisk, positive pulses. Left AV fistula site clean, scant old

blood on dressing, a palpable bruit and thrill.

Pulmonary: chest rises symmetrically; lungs clear to auscultation bilaterally and no use of accessory

muscle.

Gastrointestinal: bowel sounds present in all four quadrants, tympanic on percussion, abdomen soft,

nondistended, and no tenderness. Rectal examination negative for blood, fissures, or hemorrhoids.

Smear for occult blood at bedside was guaiac negative.

Integumentary: intact, no rashes, lesions or sores, skin turgor normal, no bruises noted.

Lymph: No lymphadenopathy noted in neck or under arms, body mass precludes detection of nodes in

groin.

Diagnostic Testing Results

The electrocardiogram shows normal sinus rhythm and the first troponin is normal.
The portable chest x-ray shows no acute cardiopulmonary disease.

Case Study Questions

1. What are the pertinent positives from the information given?

2. What are the significant negatives from the information given?

3. What is the potential cause of the patient’s fatigue?

4. Are there any other diagnostic testing (i.e. labs, imaging studies) you would order?

Provide a rationale to justify.

5. Formulate a diagnosis and treatment plan.