A Case Study: Mr. Z

Mr. Z a 40-year-old African American female went to an emergency department in local Las Vegas hospital complaining that in the past two weeks he has been experiencing nausea, febrile, fatigue, short breath, chest pain and persistent cough. He has no medical history of any disorder and does not smoke or drink alcohol on a regular basis but only engage in these occasionally with families and friends. Mr. Z respiratory rate was 32 breath per minute, heart rate 121 beats per minute, blood pressure 160/94 and SpO2 86% on room air.
Mr. Z arrived in health institution while awake and alert, though with signs of discomfort and orientated. He was obese and in tripod position on the examination table. His skin color was normal but indicated high temperature on touch. He had distress in respiration as demonstrated by lip breathing and nasal flaring. However, Mr. Z had no symptoms of peripheral or central cyanosis. Though breathing rapidly, the patient appeared to have no chest or spinal issues. He was using accessory muscles and experienced excessive diaphragm movement. There was no pedal edema or digital clubbing in the patient. His capillary refill was within three seconds. Mr. Z had rhonchi in the upper left and right lobes: contracted breath sounds in the lower left and right lobes.
Mr. Z was placed on a non- rebreather mask to raise SpO2 equal or greater than 92% and to reduce the effort require to breathe. The health care provider in the emergency room ordered a chest x-ray, ABG, sputum sample, and a complete blood count. The CBC result of Mr. Z indicated white blood cells count of 4,500. This number was below the normal range for a healthy person at her age. The ABG result revealed that he was non-compensated respiratory acidosis; PH 7.29 CO2 52 PO2 60 HCO3- 22 Base excess -2. Mr. Z chest x-ray indicated opacities in the bases of the lungs a sign of pneumonia or atelectasis. The nurse took Mr. Z sputum sample for test, and the result was positive for Pneumocystis jiroveci pneumonia or pneumocystis carnie pneumonia (PCP). Nevertheless, the patient has no history indicating the use of corticosteroids that weakens the immune system, cancer, HIV/AIDs or any other organ transplant. Further CT scan and HIV testing were ordered for Mr. Z.
The result of the blood examination result showed that Mr. Z was positive was HIV positive. The information of HIV status made Mr. Z anxious leading to increasing in respiratory distress. The complete blood count test indicated that he was experiencing malnutrition as a result of nausea. He was then taken to the Intensive Care Unit (ICU) to allow for further evaluation and treatment. Upon Mr. Z admission in the ICU, he was subjected to high flow nasal cannula; 60L flow and 50% FiO2. However, Mr. Z complaints that the high flow was hurting his nostril since he had a deviated septum. Due to the complaint, the nurse in ICU placed him on a 55% venti mask to allow for natural breathing. After 20 minutes on the 55% venti-mask, Mr.Z SpO2 declined to 82%. The nurses however acted quickly to prevent incubation of Mr. Z by placing him on continuous Bipap 50% FiO2, pressure ten over 5 PEEP. The change resulted in his stability and maintained the SpO2 at 93%.
On the next day, a night shift respiratory therapist reported that Mr. Z SpO2 decreased to throughout the night due to the pulling of the mask. He was placed later on BiPAP settings 50% 10/5 where he stayed awake, alert and orientated watching television. Mr. Z stayed in semi-fowler position. He had dry, warm, normal skin color. Mr. Z also had no signs of central or peripheral cyanosis, nasal flaring, pursed lip breathing, use of accessory muscles, excessive diaphragmatic movement, pedal edema or digital clubbing. His chest and spine had regular diameter, and his capillary refill was within three seconds.
Later in the course of the day, Mr. Z SpO2 fell below 85%, and he was seen lifting the mask off the face to release the pressure build on the bridge of the nose. When asked by the respiratory therapist the reason for lifting the mask, Mr. Z state that he was feeling pain in the nose. The therapist then placed him on the venti mask, and this allowed the SpO2 to fall to 80’s. Due to the further drop in SpO2 to 80’s, the physician move Mz. Z to a non-rebreather mask at 15Lthat is roughly70% FiO2. The mask allowed his SpO2 to rise to 99% result to comfort and reduced stress. The next day Mr. Z was intubated with an ETT 7.5 and 24cm at the lip to maintain the SpO2 at the normal level as a result of the failure of the mask. The non-rebreather mask had high oxygen content. The high oxygen content would toxic to Mr. Z if allowed to stay on it for 24 hours. The removal of the mask made Mr. Z hypoxic because his tissues were not getting oxygenated
A week later, Mr. Z was taken to a vent setting AC-VC respiratory rate 20, tidal volume 500 PEEP +10 and FiO2 60%; ETT 7.5 and 24 cm at the lip. During, his initial assessment, Mr. Z was weary but could respond to stimuli and was not distressed. He showed an RR of 22, HR of 106bpm and SpO2 of 98%. The physician was to titrate PEEP and FiO2 and keep his SpO2 at or above 92%. Mr. Z was titrated down 10% FiO2 and 2 PEEP every four hours. At the end of the procedure, the patient had a PEEP of 5 and FiO2 of 30%. His SpO2 also stayed above 94%. Mr. Z was then to receive a puff of 20mcg MDI Albuterol and eight puffs Q4. He was also prescribed to take 15mg/kg Trimethoprim-sulfamethoxazole by four for preceding 14-20 days for the treatment of Pneumocystis jiroveci pneumonia.
Pneumocystis Jiroveci Pneumonia affects patients with the vulnerable immune system. Most commonly attacked patients are those affected by HIV/ AIDS and cancer (Aimee & Feinberg, 1999). The bacterial cause pneumonia to patients. The condition can be severe and lead to death is not treated early (Aimee & Feinberg, 1999). Pneumonia can be cured by the use of antibacterial medications such as Clindamycin (Cleocin Phosphate), Clindamycin (Cleocin), dapsone, Atovaquone (Mepron) Trimethoprim-sulfamethoxazole, Trimethoprim (Proloprim) and primaquine. Treatment of the condition requires medication between 14-21 days depending on the severe level of the disorder. Besides injection, oral medication is also preferred to pneumonia patients.
HIV/AID is a chronic disease that cannot be cured. However, medication can reduce progression of the syndrome resulting to prolonged life. The disorder attacks the T-cells (T-lymphocyte cell) responsible for guarding the body against dangerous microorganism that causes disease. HIV invades and damages the CD4+ cell of T-cells then replicate unhealthy and damaged cells by changing the cell’s DNA (Krucik, 2014). The rate of replication caused by HIV is greater than the rate the body can create new healthy T-cells. The disease affects every body organ, and life expectancy of a patient depend on the time of diagnosis and treatment and the patient health. Treatment of HIV is to reduce the rate at which it progresses in the body and it effect on the T-cells. The treatment also boosts patient immune system and reduces chances of other secondary infections (Krucik, 2014). HIV changes to AIDS at the last point when the patient immune system damaged completely (all CD4+ cells have been destroyed)
HIV is treated by use of antiretroviral therapy (ART). The medical procedure involves three different drugs from two groups (AIDS.gov, 2015). ART boost patients life expectancy and reduce further transmission of HIV. The Drugs for HIV patients varies, and physicians choose the suitable treatment for each patient depending on his or her condition. Adults and Adolescent initially receive two NRTIs plus an INSTI, an NNRTI (Drugs that fight HIV, 2016). The medicines meant for HIV are grouped into six drugs according to their effect on the syndrome HIV. These categories include nucleoside reverse transcriptase inhibitors (NRTIs), CCR5 antagonists (CCR5s), integrase strand transfer inhibitors (INSTIs), protease inhibitors (PIs), fusion inhibitors and non-nucleoside reverse transcriptase inhibitors (NNRTIs)
(Drugs that fight HIV, 2016). However, the usages of these medicinal drugs change when a patient reaches AIDS stage. At this phase, the healthcare provider that decide the best medicine for the patient. The intake of HIV drugs continues for the patient entire life because the disease is not curable (AIDS.gov, 2015).
Mr. Z needs immediate extubation. There is need to complete the weaning parameters with rapid breathing examination. These trials include NIF, spontaneous respiratory rate, rapid shallow breathing index, P/F ratio and spontaneous tidal volume. If the MR. Z vital remained stable during the spontaneous breathing examination, then the weaning parameters within normal range and Mr. Z is free to start CPAP trails. Extubation of Mr. Z depends on his ability to complete tolerate and complete CPAP trials. If the patient tolerates the CPAP trials, then the respiratory therapist can carry out extubation or recommend the attending physician to be extubated.
Once Mr. Z is extubated, he would be placed in the nasal cannula to keep his SpO2 above 92%. He would also require chest physical therapy with vibration to his infected lobes. Mr. Z should also carry out incentive spirometry to intake of the alveoli. He would also need to continue taking the 14-21 day of antibiotic Trimethoprim-sulfamethoxazole and the ART for HIV. Mr. Z is also expected to continue carrying out physical therapy to remain mobile and little expansion of the lung to prevent muscle atrophy. It is also vital for Mr. Z to seek nutritional advice from nutritionist so as to consume a well-balanced diet. Through, the proper medication as stipulated by the physician and adequate exercise and consumption balanced diet, Mr. Z can have real life and increase his life expectancy.

References

AIDS.gov. (2015, August 15).Overview of HIV treatment. Retrieved October 02, 2016, from Aids.gov: https://www.aids.gov/hiv-aids-basics/just-diagnosed-with-hiv-aids/treatment-options/overview-of-hiv-treatments/
Aimee, W., & Feinberg, J. (1999, October 15). Pneumocystis carinii Pneumonia: A Clinical Review. Retrieved October 1, 2016, from American Family Physician: http://www.aafp.org/afp/1999/1015/p1699.html
Drugs that fight HIV. (2016, August 06). Retrieved October 04, 2016, from Aids info: https://aidsinfo.nih.gov/contentfiles/upload/hiv_pill_brochure.pdf
Krucik, G. (2014, October 22). Effect of HIV on the body. Retrieved October 05, 2016, from Healthline: http://www.healthline.com/health/hiv-aids/effects-on-body