Step 1 Case Study – Work through the NURSING.com Case Study together as a clinical group. Coarse crackles can be auscultated on inspiration and a wheeze is present on expiration. Nursing Case Studies is Nurse inspired and is Nurse driven. The patient has recently commenced on a low dose thiazide diuretic for hypertension. Fine crackles can be auscultated on inspiration. Coughing started 1hr ago mum gave 12xpuffs Ventolin with no relief. There is limited mobility of the diaphragm and diminished vocal fremitus. The flanks are clear of bulges. Eddie has a contusion to the back of his head and cut marks to his L) arm for which he states he ‘accidentally put his hand through his glass window’. She has been fairly healthy for most of her working life. Learn more about this type of research by reading the article. The pain has been mainly around his lower back area, at times radiates to shoulders. You note an abnormal breathing pattern of tachypnoea and moist cough. %��������� Chief complaint: The 48 year old male explains they have a six month history of intermittent back pain. Percussion: Resonance over all lung fields Auscultation: There is equal air entry into all lung fields. Lasix 40mg BD. Presentation: 68 year old man (Eddie) presents to ED via QAS from fall at home. 4 0 obj Personal history: The patient is a retired teacher. MEDICAL NURSING CASE STUDY ANSWERS Determining the order to see the clients The first client to be seen by the nurse should be the client who has unexpected or abnormal data. Palpation: Peripheral pulses are palpable at +3. Current medication Glucosamine 1500 mg. VITAL SIGNS: • Respiratory rate 24 breaths per minute • Sp02 94% on room air • Heart rate is 110 beats per minute • Blood pressure is 150/ 90 mm Hg • Temperature is 36.3°C. All questions apply to this case study. During deep palpation tenderness over the midline region is noted. R���/�_ް�3�}�&�FE�� ��yRՀ��r>d��<7�� �-F��9�Vy6Ã#VN��Y����O�'C�JS0��Z�B�=0׍JY]Wy��Uڎ���X����a���R圍uC0�ٱ��^[�a��%Nl����#����T�!�B��B� B����K? Past medical/ surgical history: She has been admitted to hospital for treatment of lower respiratory tract infection (LRTI) twice in the last year. Medical History: History of angina, hypertension, GORD, appendectomy at age 13. %PDF-1.3 There is no murmur. Palpitation: slight tenderness lower abdomen, ExpertAssignmentHelp Pty Ltd, Suite 3, Level 27, Governor Macquarie Tower, 1 Farrer Place, Sydney NSW 2000, Australia. The pain may last for a few hours or ease on rest. Irregular heart beat noted. Eddie was found on the floor by paramedics after pressing his vita-call button. You can buy a fresh copy of the solution for this assignment question. He describes the pain as a dull throb which at times gives him a sense of dread. On arrival, Eddie’s GCS was 14 and was verbally abusive to paramedics. His speech was slurred on scene and his breath smelt acidic. She has the occasional drink. Percussion: Abdomen is resonant to percuss. CARDIOVASCULAR: Inspection: The patient is centrally pink. An ECG confirmed sinus tachycardia and a portable chest radiograph showed shading in lower Left lung fields, with evidence of pneumonia. Calves are soft and non-tender. Palpation: Chest expansion is symmetrical. RESPIRATORY Inspection: The patient displays comfortable breathing, slight cough. -Vaccinations up to date Vital signs: -BP 110/72 -HR 143 -O2 Sats 92% on RA -Temp 37.3 -Resps 34. CARDIOVASCULAR Inspection: The patient is pale; slight peripheral cyanosis is present. RESPIRATORY Inspection: The patient displays comfortable breathing, nil cough. Percussion: Dull sounds can be heard over lower lung fields. Respiratory Inspection: The patient is sitting forward, using accessory muscles; she has a moist cough and is coughing regularly. 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