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Case Study – Mr Marconi, age 76. Bought in to the Emergency department at 06:00 on 1/2/2013

Mr Marconi is a 76 year Italian man who has a basic understanding of English. His current health conditions include insulin dependent type II diabetes, hypertension, hyperlipidemia and congestive heart failure.

He has been residing at a nursing home for the past twelve months. He has an unmarried daughter 56 years old who stays nearby. His wife passed away a year ago and he grieves for her today. The nurse at the nursing home arranged transfer to hospital when Mr Marconi became short of breath and stated he had chest pain. Mr Marconi has been unwell for the past 3 days with fevers; he has been refusing to eat and drink due to feeling exhausted. He had a fall this morning whilst trying to walk to the bathroom, his left wrist is swollen.

On arrival, Mr Marconi states that he has chest pain when breathing in, he is coughing up yellow phlegm and he feels exhausted. He states that he has lost several kilos over the past two weeks. His vital signs include:

•    Respiratory Rate: 28 bpm (shallow with pain on inspiration)    
•    SaPO2: 91% (2L/min)
•    Blood Pressure: 105/70
•    Pulse Rate: 105 and weak    •    Temperature: 38.9
•    BGL: 4.5
•    Weight: 78 kilos
•    Height: 174 cms

His current medications include Atenolol (beta blocker), Ramipril (angiotensin converting enzyme inhibitor) Lantus (insulin) and Lipitor (reduces cholesterol). He has no known allergies.

The doctor has noted the following in the medical record:
•    Decreased air entry and bronchial breath sounds, left lung
•    Dehydration- IV fluids commenced, 1L to run over 8 hours
•    Blood sugar 4.5, requires close monitoring.
Answer the following ten questions related to Mr Marconi’s health care:
1.        Describe the process of coronary artery atheroma formation. (150 words) Include the following in
your answer:
    a    Factors that trigger endothelial inflammation
    b    How high and low density lipoproteins contribute to atheroma formation
    c    The role of macrophages

2    You are asked to document Mr Marconi’s neurovascular observations (left wrist) during the admission assessment. Discuss the following in relation to this assessment: (100-150 Words)
    a    List the 5 parts of this assessment.  
    b    Explain how each of these assessments evaluates Mr Marconi’s left wrist injury.      

The doctor orders a chest and left forearm X-ray. The Registered Nurse asks you to organise his transfer to the radiology department.  He is scheduled for his X-ray at 06:45

3    Outline the preparation required to transfer Mr Marconi to the radiology department for these tests. Include the following aspects in your answer:
    a    Forms and documentation required
    b    Review the vital signs on the Adult Deterioration Detection System (ADDS) chart. List each of the vital signs recorded at 06:30 in the table below
            List the vital sign
Respiratory Rate    
O2 Saturation    
O2 Flow Rate    
Systolic BP    
Heart Rate    
Temperature    
4 Hour Urine Output    
Consciousness    












    c    List the abnormal signs and then describe the abnormality using correct terminology eg tachy, hyper etc
    d        ADDS Score
Respiratory Rate    
O2 Saturation    
O2 Flow Rate    
Systolic BP    
Heart Rate    
Temperature    
4 Hour Urine Output    
Consciousness    
Total ADDS    
Complete the ADDS score for each vital sign recorded at 06:30 in the table below, then total the ADDS score.

        
    e    Note the ‘Actions Required’ section of the ADDS chart and explain who should accompany Mr  Marconi when he leaves the ward to go to the X-ray department.
4    Based on the patient history, discuss at least 4 different factors that may have contributed to his fall. E.g. medication side effects, complications due to health conditions, abnormal vital signs or environmental factors (75 -150 words)

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