[Expert Solution]: Susan Patterson is a 30-year-old patient who…

Susan Patterson is a 30-year-old patient who is being admitted into the hospital for observation. She has complaints of dyspnea (shortness of breath), a productive cough, and pain along with erythema (redness) and tenderness in her right lower leg. Susan has a history of, smoking illegal substances (marijuana), and smoking three packs of cigarettes a day; she is currently using estrogen for irregular menstrual cycles and now smokes one pack of cigarettes a day. Her BP is 128/88, respiratory rate is 28, pulse 122, oxygen saturation of 89% on room air, and temperature of 99.5 degrees Fahrenheit. In the ER, blood work is drawn, and she is sent to get a CT scan and a VQ scan. D-dimer were 4 mcg/mL and her V/Q scan showed that she had a 75% chance of having a pulmonary embolism. When she gets up to her unit, the nurse does a head-to-toe physical exam. The patient is alert and oriented x4. Her pupils are PERRLA and are both at 3mm. Eyes, ears, and nose are without drainage. Face is without droop or lesions. No carotid bruits are auscultated on either side of her neck. No prominent lymph nodes are felt. Thyroid is without enlargement or nodules. Chest expansion is symmetrical. Patient seems as though she is using her accessory muscles to breath. Upon auscultation, she has bi-basilar crackles posteriorly. She is visibly tachypneic. 2 liters of oxygen was applied per order and brought her up to a pulse ox of 94%. Respiratory rate now at 22. She was put on telemetry per doctor’s order. Telemetry showed sinus tachycardia with premature atrial contractions at a rate of 120. Heart rate was irregular. S1, S2 were heard. S3 was noted when listening to the pulmonic site. Patient states that she has some sharp chest pains when taking deep breaths in. BP was rechecked and was 126/84. Overall skin appears diaphoretic and dusky in color. 2-inch white scar noted on left knee. No other openings or lesions noticed anywhere else on skin. Right lower leg appears swollen with +2 edema, bright red in color, painful to touch anterior and posterior. Hard knot is palpated on the posterior side of right lower leg. Patient able to do active ROM without much difficulty in all 4 extremities. No joint deformities seen. Abdomen flat without complaints of pain on palpation. Patient states that her last BM was yesterday. No abdominal pulsations visualized. Bowel sounds active in all 4 quads. Patient states that she is on an unrestricted diet but usually tries to eat a lot of green leafy vegetables. She states that she has no nausea or vomiting. States that her appetite has been good lately and that she usually eats 100% of her meals. When asked about urination, she states that she hasn’t been able to urinate since 8 am. She states that her urine was concentrated looking, a small amount, and foul smelling. She does not complain of frequency but does complain of some discomfort when she urinates that she rates as a 4/10 on a 1-10 scale. When checking pulses, bilateral radial pulses were +2, right pedal pulse +1, left pedal pulse +2, right posterior tibial pulse +1, left posterior tibial pulse +2, right femoral pulse +1, and left femoral pulse +2. No other edema seen anywhere else other than the right lower leg. Capillary refill >3 sec. Gait steady. Sensation intact when tested with a cotton ball on face, arms, abdomen, and leg. Biceps DTR symmetrical at +2, and patellar DTR also symmetrical at a +2. Romberg test negative. IV lock started in left hand #20 with brisk blood return. Patient tolerated well. Temperature rechecked and now at 99.8 degrees Fahrenheit. Orders received to start a heparin gtt at 10,000 units/mL and to give a heparin bolus of 5000 units IVP. Follow heparin gtt. Protocol for when to draw aPTTs. Patient’s weight is obtained at 135 lbs. She is ordered to have O2 at 2 liters to keep her pulse ox >90%. There is an order to bladder scan the patient and to obtain a urine sample for culture and sensitivity. If the patient has greater than 500 mL in the bladder, insert a catheter and consult urology. Strict intake and output. Weigh daily. Lasix 20 mg IV x1 now is ordered. Ciprofloxacin 400 mg IVPB q 12 hours, Morphine 4 mg IV q 6 hours prn for severe pain, Percocet 5-325 take 1-2 po every 4-6 hours as needed for mild to moderate pain, Lopressor 5 mg IV q 6 hours prn HR>120. Ambien 10 mg po q hs prn sleep. Smoking cessation education. Regular diet. Up as tolerated. Telemetry based on the scenario, what is the subjective data