Case Study 11
Karley Lapointe
Liberty University

Abstract
C.W. is a patient with a gastrointestinal bleed that produced a duodenal ulcer. This ulcer then produced a bloody diarrhea stool. C.W. Was brought to the emergency room with by his wife for having bloody diarrhea for three days and was presenting signs of weakness and hypotension. C.W. underwent surgery for his gastrointestinal bleed and then was admitted to the hospital for having a fluid volume deficit, due to his diarrhea and bleed. C.W. being volume deficit made his fluid, electrolyte and blood levels become very abnormal. His medication that he was on for prior health history was causing some of his levels to rise and drop. He has a past medical history of cardiovascular problems, which were described and attributed to his current admitting problems. While at the hospital he went into sinus tachycardia and was placed on a Swan-Ganz catheter. One of the main goals for treating C.W. is to control his tachycardia and control his levels. He has some serious cardiovascular conditions that can not be healed but medical professionals, using education and medication , can better his quality of the life he has left.

Patient C.W., a 70-year-old male, was admitted to the hospital at 0430 with a 25-X15-mm duodenal ulcer causing a gastrointestinal bleed, which was presented by “ dark red “ bloody diarrhea. His wife states that he has had diarrhea for 3 days with “dark red” stool starting the night before. She states that when he became “very dizzy, disoriented and weak” in the morning she decided to bring him to the hospital. He went through surgery, which was successful, but then was admitted to the medical intensive care unit for his volume deficit. C.W. has a history of having an idiopathic dilated cardiomyopathy, which has now become a severe problem, shown by an ejection fraction of 13%. He has heart failure, and had a cardiac arrest two years ago caused by hypokalemia. He also has a history of hypertension and had a peptic ulcer fifteen years ago. The Gastrointestinal bleed caused by the duodenal ulcer will first be discussed along with signs, symptoms, associated lab values, vital signs, and diagnostic testing. The Volume deficit problem will be related to his current problems and medication side effects. The preexisting conditions of cardiomyopathy, hypertension, sinus tachycardia will then be related to the gastrointestinal bleed caused by the ulcer and the medical intensive care unit admission of volume deficit along with his linking his previous conditions to his current medical state.
Pathology of First Admitting Problem The information and medical facts in this section will be taken from Porth’s Pathophysiology, chapter 45 , written by Krom unless cited otherwise. There are two different kinds of peptic ulcers, gastric and duodenal. C.W. has had a previous ulcer in the past and was brought into the hospital with a gastrointestinal bleed caused by a duodenal ulcer (Krom, 2014, p.1153-1182). The gastrointestinal tract is made up of many layers. The first one is the inner mucosa layer, which consists of smooth muscle cells. The second layer in the tract is the submucosal layer, which houses the connective tissue, blood vessels, nerves, and enzymes. The third layer is the muscular layer and it is responsible for helping objects move through the gastrointestinal tract from beginning to end. Finally, the fourth layer, is the serosal layer of the tract and it is the outermost layer. This layer is responsible for keeping the outside of the gastrointestinal tract outside and the substances inside separate from the rest of the body. Ulcers of the gastrointestinal tract are usually caused by use of medication, H. Pylori bacteria or a chronic health problem. Even with all of the layers of the tract ulcers can go through as many as all of the layers. C.W. had a peptic ulcer 15 years prior to his admission to the emergency department this time. Ulcers can reoccur spontaneously over time or can be caused by a change in day-to-day living such as: too much acid, new medications, bacteria and stress. Many of C.W.’s medications come with possible side effects of gastrointestinal bleeds and diarrhea, which lead to his bloody stool and his severe fluid deficit. The diclofenac sodium (Voltaren) has the listed gastrointestinal side effects of “ Gastrointestinal bleeding, diarrhea, peptic ulcers, bloody diarrhea, and fluid retention”(Comerford, 2011, p.729-731). Warfarin has the gastrointestinal side effect of diarrhea as well as causing ulcers ( Commerford,2011, p.501-503) All of his other medications have side effects of diarrhea but those two had the most directly correlated side effects to his original admitting diagnosis of gastrointestinal bleeding caused by a duodenal ulcer. The way that the H. pylori and medication cause ulcers are by damaging the mechanisms that produce or protect the gastric mucosa from the acidity level of the gastrointestinal tract. “ Acid injury to the duodenum is thought to promote the development of gastric metaplasia allowing the organism to colonize these areas and promote the development of duodenal ulcers” (Krom, 2014, p.1153-1182). According to Krom, some of the strongest factors that lead to duodenal ulcers are having a history of peptic ulcers , taking multiple Nonsteroidal anti-inflammatory drugs, the use of Warfarin , Which C.W. is taking 5 mg/day PO, and other medications. Some of the symptoms discomfort and pain due to the pathology of acid damage to the layers of the gastrointestinal tract, but the most common complication is bleeding. The medical staff know that C.W.’s ulcer was to the point of bleeding because of his “ dark red stool” and that when the doctors preformed his endoscopy they saw a clot starting to form on the ulcer. These ulcers commonly hemorrhage, like in C.W.’s case, perforate or penetrate. Bleeding occurs when the ulcer erodes so much tissue until it reaches and erodes the vein or artery. “Bleeding from the gastrointestinal tract also may be slow and insidious. Sometimes, chemical tests of the stool indicate a slow and subtle loss of blood” (Cleveland Clinic, 2014). For this case only showing blood in stool was how C.W.’s ulcer was made known. Perforation occurs when the gastrointestinal contents actually erode all the way into the peritoneum. Penetration is when the ulcer erodes but instead of going into the cavity erodes into another organ. The Diagnosis and treatment are fairly simple. The diagnosis is straight forward including, medical history, medications being taken, laboratory tests, endoscopic images and contrast X-rays. C.W. was on medications with ide effects that would cause this to happen, he had a history of peptic ulcers and his endoscopic image showed an ulcer that had been bleeding so his diagnosis was evident. It is preferred that while healing, and if prone to these ulcers, that blood thinners, such as aspirin, and NSAIDs are not used unless needed. Krom also discusses how the use of taking antacids regularly, especially if on medications that are known to cause ulcers, will help reduce the possible reoccurrence. “ Among the agents that enhance mucosal defenses are sucralfate and prostaglandin analogs… (these) selectively bind to the damaged ulcer tissue and serves as a barrier to acid, pepsin, and bile…(these) also initiate the secretion of bicarbonate and mucus. Misoprostol promotes ulcer healing by stimulating mucus and bicarbonate secretion and by modestly inhibiting acid secretion” (Krom, 2014, p.1153-1182). To treat C.W.’s ulcer the doctors cauterized the 25-X15-mm duodenal ulcer. According to his lab values the blood loss due to the bloody stool caused by the ulcer lowered his levels greatly. His Hgb was 8.4 g/dL when normal is 13.8-17.2 and his HCT was 25% when normal is 38.8-50%.
Second Admitting Problem Due to C.W.’s 3 day diarrhea C.W. got admitted to the medical intensive care unit for a fluid volume deficit. This was especially critical because of his intensive cardiac problems. With is cardiac ejection fraction of 13% his fluid volume being low was not helping. The following information will be taken from : Porth’s Pathophysiology chapter 39, written by Grossman , unless cited otherwise. Isotonic Fluid volume deficit can be caused by many different situations including C.W.’s excessive gastrointestinal fluid loss. It is characterized by having a decrease in the ECF. Including the circulating blood volume. C.W. is believed to be hypovolemic, which is when the circulating blood volume is affected. Diarrhea is causes the body to not be able to reabsorb fluids that are taken in and, sometimes, cause too much fluid to be passed straight into the intestinal tract. Normally only 150-200mL/day is eliminated through fecal movement. With so much fluid loss the extracellular and intracellular fluid balance is thrown off balance causing problems with the levels in the body such as the sodium, potassium, BUN and other levels along with other problems. With C.W. his levels were far from normal. His Sodium was 138 mEq/L, which was actually within normal ranges, his potassium was high at 6.9 mEq/L when normal is 3.6-5.2, his BUN was extremely high at 90 mg/dL normal is 7-20 this indicates his kidneys are failing. His creatinine is 2.1 mg/dL, which is high from the normal 0.6-1.3, again showing that with all his problems and fluid deficit his kidneys are failing. With his fluid deficit it affects many areas of the body including his already bad heart conditions. His blood pressure is extremely low when he first arrives being 70/ ? and is still low after they stop the bleeding being 98/52. His he is on blood thinners to help his heart because he has poor ejection. He has 13% right now meaning that every time his heart pumps only 13% of the blood inside is pushed out. If he wasn’t on blood thinners then the blood that is left in his heart would coagulate and form a clot that would either remain in the heart and block the valve or could eventually get pushed out causing an embolism. The blood thinners, although helpful for some aspects, caused him to bleed more and are lowering his blood pressure, which is already low because of his fluid deficit. With low fluid in C.W.’s body the kidneys are failing from their high concentration but also because his circulatory system does not have enough fluid volume or strength to push the blood to the kidneys so they are dying from lack of blood and oxygen. To treat his fluid volume deficit the medical staff did give C.W. a fluid IV catheter ,4 units of BRC and 5 units of FFP to help keep his blood pressure up by replacing what he lost with the bleed and what his body is lacking. Fluid volume deficit not only affected dehydration levels but every other system in his body (Grossman, 2014, p.1033-1041).
Co-Morbidities
C.W has had Idiopathic Dilated Cardiomyopathy for many years, which have been the factor, attributed to his heart failure problems. His heart failure problems have, in the past, caused him to go into cardiac arrest, which was found out to be caused by hypokalemia. Idiopathic Dilated Cardiomyopathy is “When the heart chambers dilate, the heart muscle doesn't contract normally. Also, the heart can't pump blood very well. Over time, the heart becomes weaker and heart failure can occur. Common symptoms of heart failure include shortness of breath, fatigue (tiredness), and swelling of the ankles, feet, legs, abdomen and veins in the neck” ( American Heart, 2015). This is shown through C.W. by his 13% ejection fraction because his chamber is so dilated and his muscles can not pump more than 13% out of his heart. At this time his lung sounds are clear but in the future the medical staff would want to pay attention to hearing crackles in his lungs as a sign of fluid build up caused by heart failure because his heart cant push the blood with enough force to get it to the rest of the body so build up in the lungs would be expected. The nurse also noted that he is having signs of pedal edema, which can be attributed to his poor blood circulation flow. He does have bowel sounds, which is a good sign meaning that his blood is getting to his bowels and those have not started to shut down like his kidneys have. His pulses are at a 2+ peripheral, which “ suggests a slightly more diminished pulse than normal” (Hill, 1990). His cardiac arrest was due to hypokalemia. When caught in time hypokalemia can be resolved by fixing itself or being given potassium chloride. With his Cardiac arrest he was unaware of his hypokalemia so he was not on his medication. On an EKG hypokalemia can be noted as: slightly prolonged PR interval, Slightly peaked P wave, St depressed and prolonged, depressed T wave (which can be inverted), and a prominent U wave (Hypokalemia, 2012). C.W. now takes potassium chloride 20mEq PO bid, to help control his hypokalemia. In his lab values that were taken, however, instead of having hypokalemia he had a large spike in his potassium levels, this can be attributed to his fluid volume deficit. With low fluid volume the concentration of potassium ratio was elevated. There is no treatment for cardiomyopathy but there is monitoring and medication that can help pro-long life. With Idiopathic dilated cardiomyopathy there is no true given reason why it occurs, it is suspected that it is passed down from family member to family member. This disease ,as shown in C.W.’s case, leads to heart failure and then to cardiac arrest. As the nurse is checking him the cardiac monitor indicates that he is in sinus tachycardia. Tachycardia is when the heart rate is faster than the normal 60-100 beats per minute (Mayoclinic, 2015) . His was 118 with respirations of 26 per minute , normal is 12-20. The nurse notes that only S3 and S4 sounds can be heard. These sounds are not normally heard. Usually only audible sounds are S1 and S2 making a LUB-DUB sound. S3 is heard after S2. The sound is when a large amount of blood enters into the ventricle quickly. This sound in a patient like C.W. confirms that the has problems with heart failure and mitral regurgitation ( shown by the 13% ejection fraction). S4 is heard immediately before S1. It is the sound of the atrium trying to push blood into a damaged ventricle, such as C.W. because of his cardiomyopathy. Hearing an S4 sounds indicates aortic or pulmonic stenosis, myocardial infarction or cardiomyopathy ( Kirton, 1997). All of which C.W. presents with. Sinus tachycardia can indicate a loss of blood or heart muscle damage. For treatment a Swan-Ganz catheter and peripheral arterial line were inserted. This does not necessarily stop the tachycardia or prevent other cardiac abnormalities but it does help the patient return to a stable condition.
C.W. has a past history of hypertension but did not present with that today. Hypertension is high blood pressure, which is another reason why he is taking Enalapril. Hypertension is when the blood that a person’s body is circulating is putting too much pressure on the walls of the arteries. The “ normal range for a patients blood pressure is 120/80. C.W. came in to the hospital with 70/ over a diastolic, which could not be read. He later had a blood pressure reading of 98/52, which had improved from when he first arrived but still is extremely low. C.W. showed signs of hypotension when he arrived at the hospital. The signs and symptoms are very similar to hypertension. He presented with signs of; dizzy, weakness, disoriented, high temperature of 99.1, high respirations of 22-26 (normal being 12-20), he was sleepy, and he was pale. He had a gastrointestinal bleed when he arrived which caused him to loose a lot of blood and fluid, which explains his low blood pressure. C.W. was being treated for his hypertension by being placed on medication. Another form of treatment for hypertension is changing your lifestyle. Some things as simple as not smoking, eating healthier and getting the proper amount of exercise can help reduce hypertension. With C.W. getting exercise would be difficult because of all of his heart problems. The medication he was on for his hypertension, Enalapril, has been known to cause a rise in BUN, Creatinine and potassium. Because of his fluid volume deficit this could explain why his levels were so high, especially if he had been taking his medications as directed up to the point of coming to the emergency department. Hypertension is diagnosed by monitoring blood pressure and with his weak heart is something that would have to be monitored and controlled constantly.
Conclusion
After receiving fluids, red blood cells and fresh frozen plasma his blood pressure was able to remain above 60 mmHg. His cardiac output has also improved and is now at 4.5L/minute. With all of his conditions the medical staff should get another set of lab values to look at his BUN and Creatinine, along with other, lab values to see if the fluids that have been given to him have helped improve those values. Also the heart and kidneys should be examined for damage from the lack of blood flow, resulting in lack of oxygen to those areas. C.W. should consult with his doctor about his medication to try to prevent a gastrointestinal bleed caused by an ulcer from happening again. C.W.’s health situation does not seem to give him much time, due to his ejection rate of 13% and his cardiomyopathy. He has improved since coming into the hospital so there is hope that he will be able to recover to his previous state but he will still have to be under close supervision of his cardiac and hypertension medical history. C.W.’s wife should be informed of his procedures that took place, his levels, any changes that could be made to his medication, his sinus tachycardia that took place in the room and any instructions that the medical staff see fit. Because of his condition medical staff should also give education to C.W. and his wife about signs of left sided and right-sided heart failure to watch out for so if the signs arise they can get medical attention as soon as possible.

References
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Cleveland Clinic. (2014). GI Bleeding Overview. Retrieved October 28, 2015, from http://my.clevelandclinic.org/health/diseases_conditions/gi-bleeding
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Grossman, S. (2014) Disorders of Fluid and Electrolyte Balance. In S.C. Grossman,& C. M. Porth, Porth’s Pathophysiology:Concepts of Altered Health States (pp.1180-1182). Philadelphia: Wolters Kluwer & Lippincott Williams & Wilkins.
Hill, R. (1990). Examination of the Extremities: Pulses, Bruits, and Phlebitis. Retrieved October 21, 2015, from http://www.ncbi.nlm.nih.gov/books/NBK350/
Hypokalemia. (2012). In Mosby, Mosby's dictionary of Medicine, Nursing & Health professions. Philadelphia, PA: Elsevier Health Sciences.
Kirton, C. (1997). Assessing S3 And S4 Heart Sounds. Nursing, 52-53.
Krom, Z. (2014). Disorders of Gastrointestinal Function. In S.C. Grossman,& C. M. Porth, Porth’s Pathophysiology:Concepts of Altered Health States (pp.1180-1182). Philadelphia: Wolters Kluwer & Lippincott Williams & Wilkins.

MayoClinic Staff. (2014, May 6). Tachycardia. Retrieved October 28, 2015, from http://www.mayoclinic.org/diseases-conditions/tachycardia/basics/definition/con-20043012?_ga=1.26752634.659069746.1402866895