Case Study

ADMITTING HISTORY
On his way to work, a 32-year-old man was involved in an automobile crash
during an ice storm. His car hit a patch of ice, spun out of control, and hit a cement
bridge support. The fire department spent 90 min extricating him from the car. He was
stabilized at the crash site and then transported to the hospital. Although he was
unconscious, he started to move and speak en route to the hospital. His speech was
incoherent.
On admission, he was hypotensive, conscious, and complaining of severe pain.
When he was asked to identify specific pain sites, he stated that his whole body hurt.
He had numerous facial lacerations and several broken teeth. The left zygomatic arch
and his right maxilla were fractured. He had a compound fracture of the left humerus
bone; a fracture of the left radius; and several simple fractures of the first, second, and
third phalanges on his left hand. A large bruise in the shape of a steering wheel could
be easily seen over his anterior chest. He had splintered fractures of his right tibia and
fibula. Although the chest x-ray taken in the emergency room showed no rib fractures,
bilateral patchy infiltrates could be seen throughout both lungs.
He was taken to surgery, where maxillofacial, plastic, and orthopedic surgeons
worked to treat his multiple injuries. The patient was in the operating room for 16
hours. His surgery was described as successful, and the long-term prognosis was
believed to be good. He was in the post anesthesia care unit (PACU) for 2 hours with
no remarkable problems and then was transferred to the surgical intensive care unit
(SICU).
On arrival in the SICU, the man was breathing on his own, receiving
supplemental oxygen via a 2 L per minute nasal cannula. His general
cardiopulmonary status was stable, and his recovery for the first 24 hours was as
expected. At that time, however, the patient began to show signs of respiratory
distress, and the attending physician ordered a respiratory care evaluation.

PHYSICAL EXAMINATION
The respiratory therapist assigned to assess and treat the patient gathered this
clinical information: on inspection, the patient was in moderate respiratory distress.
He appeared uncomfortable and complained that he could not move very well and that

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he was becoming short of breath. He stated that he had never been a smoker. His
blood pressure was 125/78, heart rate 93 bpm, respiratory rate 21/minute, and core
temperature normal. His skin appeared pale, and when he was asked to cough, he
demonstrated an adequate although nonproductive cough. On palpation, tenderness
was noted over his anterior chest area bilaterally, and dull percussion notes were
elicited over both lower lung regions. On auscultation, bilateral bronchial breath
sounds were heard. His oxygen saturation measured by pulse oximetry (SpO 2) was
95%, and his arterial blood gas values (ABGs) on a 3 L per minute oxygen nasal
cannula were as follows: pH 7.51, PaCO2 29 mm Hg, HCO3– 22 mEq/L, and PaO2 68
mm Hg. His chest x-ray showed “ground-glass” infiltrates throughout both lung
fields. The process was more extensive than that noted on admission to the emergency
department.

Figure: Chest x-ray of a 32-year-old man with acute respiratory distress syndrome
(ARDS)
Based on the above clinical data, how would you SOAP this patient? (SOAP 1)

3 DAYS AFTER SURGERY

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 3

The patient paged the nurse and stated that he was feeling worse. Respiratory
care was called. On observation, the patient appeared weak and cyanotic. His
respiratory rate was 30/minute, blood pressure was 165/95, heart rate was 110 bpm,
and rectal temperature was 38.8°C (101.8°F). His cough was still nonproductive, and
his anterior chest was still tender. Bronchial breath sounds and crackles were heard
throughout both lung fields. His ABGs on an FIO 2 = 0.80 were as follows: pH 7.56,
PaCO2 24 mm Hg, HCO3– 18 mEq/L, PaO2 35 mm Hg, and SaO2 77%. No recent
chest x-ray was available, but one had been ordered.

Based on the above clinical data, how would you SOAP this patient? (SOAP 2)

30 MINUTES LATER
The respiratory therapist assigned to monitor and evaluate the patient noted
that the patient’s respiratory rate was 18/minute, blood pressure was 170/97, heart rate
was 150 bpm, and rectal temperature was 37.8°C (100°F). He appeared cyanotic, and
he no longer responded verbally when asked questions. On auscultation, bronchial
breath sounds and crackles could be heard bilaterally. His ABGs on CPAP at 10
cmH2O and an FIO2 1.0 were as follows: pH 7.31, PaCO 2 48 mm Hg, HCO3– 22
mEq/L, PaO2 31 mm Hg, SaO2 54%. A current chest x-ray showed increased opacities
throughout both lung fields.

Based on the above clinical data, how would you SOAP this patient? (SOAP 3)

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