Smith Male Years Explained for Students (Easy Guide)
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Original Question
Mr. Smith, male, 75 years old, admitted to the ER last night via rescue with complains of: Pain “all over”, headache, weakness, SOB and poor skin turgor. Rescue call placed by neighbor. Neighbor reported found pt. outside his trailer naked sitting on stairs, babbling. Weight: 122 #s, Height: 5′, 10″, Hispanic, primary language: Spanish (speaks some English) Pt. widower for 10 years, one son, out of state. Hospital Hx.: BPH, HTN, DM (type 2), CHF, HF, PAD, CRF (3), L foot neuropathy Allergies: PCN, ASA, Diflucan Home Meds: Unknown Assessment: AAO x 2 (oriented to self and day or night only), Rales R lung base, R flank pain, sunken eyes, VS: BP: 100/60, R: 36, HR, 115, T: 102.7 F, Pain: 5, POx: 93 % (From ER, 3 hours ago). Now the patient comes to your unit (0800) with the following results and orders. LABS: Glucose: 360 HGB: 8.7, RBC: 5.9, HCT: 39 % WBC: 18575 Na: 148, K: 5.9, Ca: 10.6 mg/dL Urine: Dark yellow, strong odor, Ph: 5.1, glucose ++, SG: 1.055 GFR: 40 PO2: 79, pH: 7.30, PCo2: 39, HCO3: 16 Questions: Describe the clinical situation of the patient. Which are the 3 most critical labs results and what will you do about it. Implement 3 interventions in order of priority. Create a care plan for the most critical of the situations. Which medications, if any, will you recommend to administer and why? Which other, if any, labs or test will you suggest need to be done? Will you recommend any consultation? If yes, with whom and why? Will you educate the patient if yes, about what and why?
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