A 64-year-old man presents to the emergency department for the Completion checkbox for Pulmonary System. His wife reports that he seemed “out of sorts” yesterday and had slight numbness in the left leg throughout the day, which was attributed to “arthritis”. This morning he woke with left-sided weakness, slurred speech, and was unable to get out of bed without assistance.
Past medical history
- Hypertension treated with a thiazide diuretic and calcium-channel blocker
- Stable angina pectoris: treated with nitroglycerine sublingual as needed, recent electrocardiogram and stress test results unremarkable
- Annual influenza vaccine received and COVID-19 vaccines received within the past year
- No known allergies or intolerances
- No recent hospitalization or antibiotic use
Vital signs
- Heart rate = 74 beats/min, sinus rhythm
- Respiratory rate = 16 breaths/min, regular and unlabored
- Blood pressure = 140/85 mm Hg
- Oral temperature = 98.2 degrees Fahrenheit
- Oxygen saturation = 92% on room air
- Pain = 0/10
Physical examination results
- Neurologic – eyes open spontaneously, speech garbled, moves on command, left extremities with decreased sensation and weak 3/5, left facial droop present, gag reflex diminished, gaze midline, extraocular movements present without deviation
- Cardiopulmonary = S1 and S2 to auscultation, right carotid artery with bruit, peripheral pulses 3+, and no jugular venous distention. Extremities warm, edema absent, pulses 3+, capillary refill brisk. Lung sounds clear.
Diagnostic test results
- Computed tomography of the head without contrast = findings unremarkable
- Chest x-ray = findings unremarkable
- Swallow study = dysphagia with thin liquids
- Carotid ultrasound = right carotid artery 30%-40% occlusion
- Arterial blood gases = results within normal limits
Hospital course
He was diagnosed with an ischemic stroke. The stroke team determined no emergent thrombolytic or invasive intervention was indicated, and the patient was admitted to the stroke unit. The left-sided weakness and expressive aphasia persisted.
On the 4th hospital day, he became febrile with a temperature of 102.8°F with frequent coughing, productive of purulent sputum. He also had slight tachycardia, tachypnea, and a decreased oxygen saturation on room air. Rhonchi and crackles were heard throughout right lung.
New diagnostic results revealed
- Chest x-ray = right lobe infiltrate without an associated pleural effusion
- White blood cell count = 20,000 cells/mcL (normal = 4.0-10.0 1000 cells/mcL), with a predominance of neutrophils
- Arterial blood gases on room air: pH = 7.45 (normal 7.35-7.45), partial pressure of oxygen in arterial blood = 70 mmHg (normal 75-110 mmHg), partial pressure of carbon dioxide in the blood = 38 mmHg (normal = 35-45 mmHg)
- Sputum culture – early results positive for Pseudomonas aeruginosa
- Read the scenario below and identify the likely acute pulmonary complication the patient is experiencing.
- Explain the underlying pathophysiology (aka. cellular/tissue changes) and relate it to abnormal examination and diagnostic findings.
- Identify bundled prevention care strategies that should have been initiated upon admission to prevent this specific healthcare-associated pulmonary complication. Hint: See supplemental materials in weekly module.
- Explain additional diagnostic testing, medical treatment, and nursing care to treat the patient and/or prevent future complications.
