Scenario 1
Presentation: 68-year-old man with breathing problems
History: A 68-year-old man with chronic renal failure was in the hospital in serious condition recovering from a heart attack. He had just undergone “balloon angioplasty” to redilate his left coronary artery and was thus on an “NPO” diet (i.e., he was not allowed to have food or drink by mouth). He received fluid through an intravenous (IV) line. Late one night, a weary nurse who was on the 11th hour of a 12-hour shift came into the patient’s room to replace the man’s empty IV bag with a new one. Misreading the physician’s orders, he hooked up a fresh bag of IV fluid that was “twice-normal” saline rather than “half-normal” saline (in other words, the patient started receiving a fluid that was four times saltier than it should have been). This mistake was not noticed until the following morning. At that time, the man had marked pitting edema around the sacral region and had inspiratory rales (“wet-sounding crackles”) at the bases of the lungs on each side. He complained that it was difficult to breathe as well. A chest x-ray revealed interstitial edema in the lungs. Blood was drawn, revealing the following:
Na+ 157 mEq / liter (Normal = 136-145 mEq / liter)
K+ 4.7 mEq / liter (Normal = 3.5-5.0 mEq / liter)
C1- 101 mEq / liter (Normal = 96-106 mEq / liter)
Questions: Choose to answer one of the two question sets to serve as the basis for your initial response:
Question Set 1
1. Most dissolved substances in the blood plasma can easily move out of the bloodstream and into the interstitial fluid surrounding the cells. Will the nurse’s mistake increase or decrease the “saltiness” of the interstitial fluid?
2. Why does this patient have pitting edema and inspiratory rales?
3. Can you think of any other normal mechanisms that the body has to control salt and water balance? How might they react in this situation?
OR
Question Set 2
1. Most dissolved substances in the blood plasma can easily move out of the bloodstream and into the interstitial fluid surrounding the cells. Given your knowledge of osmosis, will this cause the cells in the body to increase or decrease in size? Explain your answer.
2. How would this increase in salt load affect the patient’s blood-aldosterone level? In your answer, explain the function of the hormone aldosterone.
3. What symptoms might result from hypernatremia (“high blood-sodium” level)?
Discussion 2 – Scenario 2
Presentation: 62-year-old man with esophageal bleeding
History: Vincent Miller, a 62-year-old accountant, has had a “drinking problem” throughout most of his adult life. He drinks about a half-case of beer each day. He has lost several jobs over the years for drinking at the workplace or showing up for work drunk. He lost his driver’s license for drunk-driving, and his drinking has placed a considerable strain on his marriage. He has tried several self-help programs as well as Alcoholics Anonymous, all with little success. He has been hospitalized on several occasions over the years. Vincent has a severe tremor in his hands (probably due to excessive alcohol intake), which makes it exceedingly difficult for him to use a spoon, fork, and knife to eat. It is your first day on the job as an occupational therapist, and you are consulted by his physician to see if there is any way to help Vincent use eating utensils. Not knowing anything about him, you open his past medical records, which, incidentally, are quite thick.
Questions: Choose to answer one of the three question sets to serve as the basis for your initial response.
Question Set 1
First Hospitalization:
You note that Vincent was hospitalized at age 32 with a complaint of vomiting up blood after a drinking binge that lasted seven days and was marked by excessive and repeated vomiting episodes. The vomitus was bright red.
The hospital chart lists a diagnosis of “Upper GI bleed” due to a Mallory-Weiss tear. You look up “Mallory-Weiss tear” in an internal medicine textbook and see that it is defined as “a longitudinal tear in the mucosa at the gastroesophageal junction — i.e. in the area of the lower esophageal sphincter — caused by repeated vomiting.”
1. Why was the blood bright red, rather than the color of “coffee grounds”?
2. Based upon your knowledge of the vomiting reflex, why might severe vomiting tear the mucosa?
OR
Question Set 2
Second Hospitalization:
At age 36, Vincent was hospitalized again, this time with complaints of abdominal pain in the upper epigastric region (i.e., just below the xiphoid process of the sternum) and “coffee-grounds” emesis. He also complained of “heartburn” (a burning sensation in the area of the sternum) which was partially relieved with antacids. A diagnosis of “upper GI bleed due to gastritis and reflux esophagitis” is noted in the chart. A diagnosis of “upper GI bleed due to gastritis and reflux esophagitis” is noted in the chart.
1. What is causing the pain in the upper epigastric region? What barrier(s) normally protect the stomach lining from its own acid?
2. What is reflux esophagitis?
OR
Question Set 3
Third Hospitalization:
At age 41, Vincent entered the hospital with complaints of a high fever, nausea, loss of appetite, and a dull, continual pain in the left side of the back. In addition, he had diarrhea of a particularly foul odor and yellow color. He had also lost 15 pounds over the last month and a half. Unfortunately, the page in the chart is torn, so you cannot read the diagnosis! But your memory of an anatomy and physiology course you took in college helps you figure out the plausible causes of Vincent’s problem.
1. Excessive exposure to alcohol can cause inflammation of certain digestive organs, such as the stomach. Inflammation of which organ(s) might be causing Vincent’s back pain?
2. Based on the organ’s function, what is causing the “steatorrhea” and weight loss?