Question
Answered step-by-step
Asked by tessy1703
Patient Initials Age Weight & Height Gender Service Consults AllergiesÂ
C. Carter 49
210lb.
5’9
M Gastroenterology  ibuprofen, lisinopril, throdrenaline, theophyiline, tomato’s. Reaction: hives/rash
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Patient Health History
COPD, asthma, alcohol abuse (8-12 beers a day), hypertension, tobacco abuse, acute bronchitis, cholecystectomy,Â
Pt presented to the Integris-Yukon ED with 9/10 chest pain and was discharged to home with dx of asthma exacerbation and UTI and prescribed prednisone and ciprofloxacin. Pt came back to Integris-Yukon ED two days later (9/12) with complaints of nausea, vomiting and abdominal pain. A non-infused CT of the abdomen showed possible pancreatitis. The second CT showed some short bowel thickening and possible right colon thickening. He was then admitted for acute pancreatitis. Â
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MAR for C. Carter
Medication Classification Dose/Route/Time  Scheduled Times: Indications/Use
Dilaudid Opioid algentic 0.5mg/oral/ q3 hrs PRN PRN Pain medicationÂ
labetol antihypertensive 5mg/IV/q 6hrs 0900, 1500, 2100, 0300Â Decrease BP
reglan prokinetic 10mg/IV/q 6hrs 0900, 1500, 2100, 0300 Treats nausea and vomitingÂ
Dextrose 5% IV solution glucoseÂ
40ml/IV/PRN
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PRN
*To be given for FSBS <50 mg/dL Reduces concentration of glucose in blood Novolog antidiabetic 100units/mL/IV/q 4hrs *175-210= 1unit 211-245=2 units 246-300=3 units 301-345=4units >400 notify MD
Treats high blood sugar
Fluticasone-vilanterol Glucocorticoid 1 puff/resp/daily 0900 Treats COPD
Pepcid H2-histamine receptor antagonist 20mg/IVBID 0900, 2100Â Treatment of ulcers
Lovenox Anticoagulant 40mg/subcut/bedtime 2100 For prevention of DVT
Flagyl Antiinfective 500mg/IVPB/q 8 hrs 1200, 2000, 0400 Prevent infection
Duoneb Anticholinergic 3mL/resp/q 6hrs PRN PRN To treat & prevent wheezing or shortness of breathÂ
Adult central TPN Solution Daily nutrition Continuous @ 100ml/hr 1800 start new bag Nutrition
Ciprofloxacin in dextrose 5% Antibiotic 400mg/IV/q 12 hrs (BID) 0900, 2100 Prevention of infection
Lomotil Antidiarrheal 2 tab oral q 6 hrs 0900, 1500, 2100, 0300 Decrease diarrheaÂ
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System AssessmentÂ
Neuro/Sensory Awake, Alert and oriented x4; states no dizziness on standing. Â
Cardiovascular
BP:139/88 Pulse:78
normal heart rate and regular rhythm with no evidence of murmursÂ
cap refill: 2+ pedal pulse:2+ no edema, no cyanosis or clubbingÂ
Respiratory
RR: 18 O2 sat:93% at room airÂ
no shortness of breath, no wheezing or coughing, no secretions;Â
clear lung sounds bilaterally and in all lobes; even & unlabored respirationsÂ
GI
NPO
a gtube in place to left upper quadrant;Â
no nausea or vomiting at this time
persistent diarrhea; (+) guiac occult testing
liquid stool x4 this shiftÂ
abdomen distended and firm, tender on palpation (most tender in upper R Q)
Bowel sounds hypo-active in all quadrants
Intake: PO-0Â IV: 1250mL
GU
foley catheter intact; Output: 1188 mL
urine: yellow, clear, no sediment
No flank tenderness to palpation;
Skin
Temp:98.9 FÂ
Skin is warm, pink and dry with poor turgor;Â
with no rashes, jaundice noted
no evidence of breakdown over bony prominences
Braden scale:20,Â
picc line in R arm with IVF infusing. No redness or swelling at insertion site.
Musculoskeletal
assist when ambulating—pt states “I feel so weak.” Â
Normal ROM in all extremities, grips/strength equal bilaterally
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Endocrine
FSBSÂ 0800:221
1000: 188Â Â Â Â Â 1200: 201
1400:Â 196Â Â Â Â Â Â 1600:Â 155
No history of thyroid disorders
Reproductive No complaints at this time. Catheter Care performed no skin breakdown noted.
Pain
c/o severe pain in lower abdomen 8/10 on pain scale.
Pain is described as stabbing and constant
Pt reports pain as 5/10 after IV pain meds
Psychosocial Pt states that he has good supportive wife, 3 children, and a job he enjoys
Labs/Diagnostics
WBC: 18,000Â Â RBC: 4.9 hemoglobin: 14.3 hematocrit: 41.6
Amylase:Â 124Â Â Lipase:Â Â 158
Triglycerides: 277Â Â BUN: 8.0Â Â Creatinine:Â 1.0
Sodium: 142Â Â Potassium: 4.0Â Magnesium: 2.0
Chloride: 100 Â Â Phosphate: 3.0Â Â Â AST: 31Â Â ALT:Â 36
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Miscellaneous Â
Based on Mr. Carter’s clinical manifestations (assessment) and lab results, the health care provider suspects the patient has Pancreatitis and possibly an inflammatory bowel disease. What information from the chart supports the diagnosis?Â
Pancreatitis :
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Inflammatory bowel disease:
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 The patient has a capsule endoscopy done (swallows a camera pill) as a diagnostic test. Results show areas of inflammation in the mucosal layer of the colon only.Â
These findings are characteristic of what specific inflammatory bowel disease?
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How are each of the inflammatory bowel diseases differentiated?
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 What clinical data from this chart is RELEVANT and needs to be trended because it is clinically significant?Â
*in other words—what labs, vitals, symptoms should be watched closely since they indicate a potential complication?
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What are the most likely complications to anticipate based on the patient’s diagnoses and clinical manifestations (assessment)?
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What interventions would prevent these complications from happening?
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SCIENCE
HEALTH SCIENCE
NURSING
NURSING 1118