Evaluating the Case of A 69-year-old Man

Case Study 1
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Summary of the Problem
This is a case of a 69-year-old man who suddenly suffered from an acute respiratory distress syndrome, with associated changes in mental status. Currently, the patient’s vital signs are as follows: blood pressure that increased from 150/99 mmHg to 185/110 millimeters of mercury (mmHg), a cardiac rate that increased from 125to 140 beats per minute (bpm), respiratory rate of 35 cycles per minute (cpm), and peripheral oxygen saturation (SpO2) of 85%. These are significantly higher than the average values except for the SpO2, which is significantly lower. The main problems were inadequate assessment, inappropriate drug prescription, and supportive measures, and proper referral.
Context Assumptions
Assessment of the Mental Status Changes
The first problem was the inadequate assessment of the patient’s clinical condition. It has been noted that the patient was stable 4 hours ago (at 0800) then deteriorated at 1200. Furthermore, the patient’s condition rapidly progressed five minutes after, creating a sinus tachycardia and further increasing the mean arterial pressure to 135 mmHg. In this case, the patient could probably be suffering from an impending respiratory arrest related to the mental status changes.
Shebl & Burns (2020) mention that an impending respiratory failure can be due to a central nervous system problem that depresses the respiratory drive or obstruction of the upper and lower airways. The latter has a higher probability for the patient since he had a history of asthma. Moreover, Lewis (2021) suggests that mental status changes and restlessness, as manifested by myoclonic jerks, indicate respiratory acidosis. This prompts the assessment of the patient’s arterial blood gases. Assessment of the case is significant to manage the patient’s condition properly. Inadequate assessment leads to poor diagnosis, leading to inappropriate treatment. Further examination of the mental status changes must be done. This can be quantified using the Glasgow Coma Scale (Patti & Gupta, 2017).
Norepinephrine Infusion
Second, the patient was given norepinephrine infusion at 10 mcg/min, which will be increased to 15mcg/min. This is a sympathomimetic drug that acts at alpha-1 and beta-1 adrenergic receptors. When given at doses greater than 2mcg/min, it mainly acts on alpha-1 receptors, resulting in vasoconstriction, leading to increased systemic vascular resistance. This also decreases the oxygen supply to the end-organs, particularly the brain, ultimately inducing brain injury secondary to cerebral vasoconstriction and diminished cerebral blood flow (Smith & Maani, 2020; Heming et al., 2020). The drug is contraindicated for the patient due to high blood pressure, mean arterial pressure, and the already reduced brain oxygenation, as manifested by the decrease in SpO2 and altered mental status.
Fentanyl
Second, fentanyl, which will be increased to 150mcg/hr, is contraindicated in ARDS because it results to further respiratory depression by reducing the central and peripheral ventilatory chemoreceptor gains and direct inhibition of respiratory nerve activity (Algera et al., 2019...