A. Taking into account the patient’s age, history of diabetes and hypertension, medication intake (ACE inhibitor, glucose-lowering oral medication and a diuretic) and poor objective status, it is reasonable to: 1) assess her skin and mucus membranes (elevated blood glucose suggests dryness), 2) softness of eyeballs (assessment of diabetic coma), 3) peripheral pulse filling (suggesting hypotension due to ACE over dosage), 4) oral odor (suggesting ketonemia), 5) blood pressure, 6) glucose blood check, 7) room air saturation, 8) airways since she complaints of breathleness, 9) neurological condition because she had an episode of syncope (to rule out the stroke). Her level of pain can be appreciated by her face look as well as reaction to pain stimulus, like pressure on the nail or eyeball. Other routine observations that need to be paid attention to: 1) cardiovascular system: irregular heart sounds may suggest atrial fibrillation, A2 accent may mark arterial hypertension (hypertonic crisis), ECG reveals ischemia. This is an extremely important tool since a patient with diabetes may develop painless acute coronary syndrome. Peripheral pulse on feet demands skin evaluation too since these two observations may suggest diabetic foot syndrome, 2) pulmonary status: auscultation may suggest pneumonia. In diabetes and in geriatrics, pneumonia may exacerbate the generally poor condition. Should suspicion occur, X-ray is indicated, 3) gastrointestinal status: stool is extremely important because melena as a marker of gastrointestinal bleeding will for sure make the patient critically ill. If bleeding is suspected, fibroscopy is further indicated, 4) renal status – diuresis must be carefully assessed because both arterial hypertension and diabetes lead to renal impairment. Urinalysis may detect proteinuria and biochemistry shows elevated creatinine level, 5) neurological status – should the stroke be suspected, MRI is indicated.
B. Non-invasive blood pressure with a cuff by Korotkoff’s sounds: this is a cheap, easy, reproducible and fast tool to measure the blood pressure. Blood glucose check: accu-check strip takes 5 seconds to know what the glucose level in the individual is, its handling is easy and demands no sophisticated skills. ECG is a tool to detect electrical activity of the heart. This is a fast and available tool to appreciate myocardial oxygenation status and rhythm control. X-ray beams machine beams X-rays through the body. Abnormalities within the chest delay the X-rays depicting specific pictures suggesting pneumonia, pneumothorax or other conditions. Fibroscopic investigation is essential in gastrointestinal bleeding management. This tool visualizes the exact site of bleeding and helps to achieve homeostasis in most cases. All these tools are generally easily available, but deliver important information about the patient’s condition and in most cases suggest further therapeutical approach. Special attention must be paid to the cardiovascular system, since advanced age, hypertension and diabetes are evidence-based risk factors of ischemic heart disease. Should coronary status be suspected, an echocardiogram is to be taken to follow areas of hypocinetic myocardium. Further diagnostic and treating interventions include coronarography. This is a more sophisticated method available to cardiology departments. In this tool, the coronary arteries are visualized and ballooned or stented to treat the acute coronary syndrome.
C. The patient’s risk factors suggest she suffers from: 1) cardiovascular disorder very probable. Both age, diabetes and hypertension history cause atherosclerosis. The plaques that are most dangerous according to the clinical worsening might explain ischemic heart disease (however, they may be in the carotid arteries too). Coronary syndrome if untreated leads to high morbidity (congestive heart failure, arrhythmias) or mortality (sudden cardiac death, ventricular fibrillation), 2) uncontrolled diabetes may contribute to her poor condition. She takes oral glucose-lowering agents. Thus, she most probably suffers from diabetes type II. In this case, hyperosmolar coma is frequent. Blood glucose is essential to control in a diabetic patient even if the condition is unrelated to diabetes decompensation itself, 3) she started new long-lasting ACE inhibitor. Uncontrolled blood pressure may be the leading problem here. So, her blood pressure must be checked as soon as possible, 4) she had a syncope, and the stroke must be ruled out by searching for neurological deficits. Thus, the scenario is prioritized according to the life threatening conditions and their probability in this particular case.
D. An alert patient is assessed by interviewing: orientation to person, place and time, asking questions and appreciating answers. The health care giver should try to assess her pain level asking her to rate pain on a scale of 1 to 10. 1 corresponding to no pain and 10 being the worst pain she has ever felt. Otherwise, this is done by assessing pupil reactivity, and inspection how Mrs. Baker experiences pain by moaning, agitation, restlessness and facial grimacing.
E. If the patient is not alert, oral acetaminophen is probably not the choice route of administration. IM morphine, on the other hand would absorb from the muscle for a prolonged period and its effect may be too long interacting with the general stunning condition. Thus, IV morphine that acts fast and absorbs rapidly is a more controlled mode of pain relieving. The result is derived from dynamics of pupil reactivity, her moaning, agitation, restlessness or facial grimacing
F. Emergency room nurse must response adequately and fats if respiratory distress worsens. Mask oxygen is given as soon as possible. IV route is placed since medicines (insulin, fluids, heparin) act faster than through other types of administration. An anesthesiologist may be invited to check if the patient needs intubation and mechanical ventilation. A cardiologist must check her cardiac status. An endocrinologist may be involved to assess her diabetes state.