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Original Question

Kindly create your case study analysis basing on the information of a given caase below with the presenting signs and symptoms. Kindly follow this format in creating your case analysis Present the case of the patient (observe anonymity) Patient’s Identification Date of Admission Time of Admission Chief Complaint Admitting Diagnosis a. Background of the Chief Complaint (History of Present Illness) (specifically include the experiential perspectives) Chief complaint contains (CC) single complaint and duration; history of present illness has descriptive first sentence that includes CC, relevant critical history, patient age, location and nature of visit (to any health care facility); contains comprehensive description of symptom attribute (PQRST/OLCART). b. Risk Factors (Internal and External Perspectives) Present at least 5 relevant risk factors that could have contributed to the development of the client’s problem; every risk factor must be well-supported by at least one scientific evidence justifying (pathophysiologic perspectives) its link to the client’s problem. AGE. Description, with evidence GENDER. Description, with evidence c. Physical Assessment (behavioral perspectives) Contains a thorough description of all positive and negative examination findings in each of the following areas: General, vital signs (including height and weight), HEENT, Neck, Thorax, Cardiac, Pulmonary, Chest, Abdomen, Rectal/Pelvic/Genital, Neurologic, Musculoskeletal, and Peripheral Vascular. Items in the examination include a positive finding that supports the impression and is consistent with the history. General Appearance: Vital Signs: Height: Weight: HEENT: Neck: Reference: https://www.referencepointsoftware.com/article-write-a-nursing-case-study-paper/ Basis of the Case Study Analysis: Case: The patient is a 41-year-old male who has a long-standing history of hypertension and diabetes mellitus and presents with a complaint of pruritis, lethargy, lower extremity edema, nausea and vomiting. He denies any other medical illnesses. On physical examination the patient is a well-developed, well-nourished male in moderate distress. Blood pressure 180/110, pulse 80, respirations 24 and he is afebrile. Body weight 76.5 kg. Cardiac exam has an S1, S2 and S4. The remainder of the exam is remarkable for 2+ lower extremity edema and superficial excoriations of his skin from scratching. Laboratory Values are as follows Results Normal Values Sodium 133 136-146 mmol/L Potassium 6.2 3.5-5.3 mmol/L Chloride 100 98-108 mmol/L Total CO2 15 23-27 mmol/L BUN 170 7-22 mg/dl Creatinine 16.0 0.7-1.5 mg/dl Glucose 108 70-110 mg/dl Calcium 7.2 8.9-10.3 mg/dl Phosphorus 10.5 2.6-6.4 mg/dl Alkaline Phosphatase 306 30-110 IU/L Parathyroid Hormone 895 10-65 pg/ml Hemoglobin 8.6 14-17 gm/dl Hematocrit 27.4 40-54 % Additional data are as follows: 24-hour urine collection at 850 ml Renal ultrasound: right kidney 9 x 6 cm; left kidney 9.2 x 5.8 cm Both kidneys illustrate hyperechogencity and no hydronephrosis

 
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