[Answered]: Chapter 30Myasthenia Gravis ADMITTING HISTORYA…

Chapter 30Myasthenia Gravis ADMITTING HISTORYA 62-year-old male, with a known history of diabetes Type II, hypertension, and hyperlipidemia, was seen by his family physician for complaint of chronic fatigue, double vision, and trouble in keeping his balance while walking. The patients spouse stated that her husband was having trouble chewing and swallowing his food for the past few weeks. She further stated that her husband had lost about 10 lb during the same period. While interviewing the patient, the physician noted that the patient was having trouble speaking and that the patients right eyelid was drooping. Suspecting that the patient was demonstrating several of the clinical manifestations associated with myasthenia gravis, the physician had the patient admitted to the hospital for a more thorough evaluation.Over the next 48 hours, the patient received a number of tests and bedside evaluations, including a neurologic examination, an edrophonium test, an ice pack test, and an electromyography assessment. Within moments after receiving a test dose of edrophonium, a dramatic improvement was observed in the patients muscle function that lasted for about 10 minutes. Later, during the electromyography evaluation, the patient was unable to gaze upward or blink continuously for more than 15 seconds. After an ice pack was applied to the patients right drooping eye for 5 minutes, the separation between the upper and lower right eyelid increased by 5 mm. Based on all these findings, the attendant entered the diagnosis of myasthenia gravis in the patients progress notes. The patient was started on pyridostigmine and prednisone. Respiratory care was asked to evaluate the patient for any needed therapy and to monitor the patients ventilatory mechanics for any clinical signs of acute ventilatory failure.The respiratory therapist assigned to the patient noted clear lungs throughout the patients lungs. When the patient was instructed to cough, however, a moderate amount of clear/white sputum was expectorated. To offset the airway secretions, and the possibility of mucus plugging and atelectasis, the respiratory therapist initially started the patient on positive expiratory pressure (PEP) therapy and incentive spirometry (IS). The patients vital capacity (VC), negative inspiratory force (NIF), and pulse oxygen saturation (SpO2) were monitored Q2h.Initially, the patients VC was 3200 mL and his NIF was a -43 cmH2O. His SpO2 was 94%. Unfortunately, over the next 3 days, the patients overall respiratory status progressively deteriorated. His VC dropped to 1760 mL and his NIF decreased to a -18 cmH2O. Arterial blood gases on a 4 L per minute oxygen cannula were as follows: pH 7.26, PaCO2 68, HCO3 27, PaO2 63, and SaO2 88%. At this time the patient was intubated and placed on a mechanical ventilator with these settings: volume control, 12 breaths/min, tidal volume 0.5 L, FIO2 0.5, and positive end-expiratory pressure (PEEP) of 5 cmH2O.Twenty minutes after the patient was on the ventilator, his vital signs were as follows: blood pressure 130/85, heart rate 85 bpm, and rectal temperature 37deg C. Auscultation revealed fine and course crackles throughout both lobes. Increased tactile fremitus was also noted over the lower lung region. A moderate amount of white secretions was sucked from the endotracheal tube. A portable chest radiograph showed numerous patches of atelectasis throughout both the right and left lower lung lobes. An arterial blood gas showed the following: pH 7.52, PaCO2 28, HCO3 21, PaO2 146, and SaO2 98%. On the basis of these clinical data, the respiratory therapist entered a SOAP in the patients chart. Based on the above clinical data, how would you SOAP