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Nursing Case study 1

Chief complaint: A 70 year old female patient [Kim] is admitted with a history of chronic, productive cough, breathlessness, and generalised malaise over the past year. Over the last two months she has noticed trouble with sleeping at night due to coughing and is generally feeling increasing tiredness. She is having difficulty with activities of daily living (ADL) due to weakness, exhaustion and breathlessness. For the past 24 hours he has also been suffering from chest tightness; however the patient denies any pain.
Personal history: The patient is a retired teacher. She has been fairly healthy for most of her working life. She exercises occasionally and has gained weight over the past 20 years however over the last 6 months has lost weight. She has been widowed for the last five years. She has two adult children, only one who lives in the same city. Kim smoked one packet per day of cigarettes since her early 20’s and describes herself as being ‘prone to chest infections’ including wheeze and chest tightness for the past number of years. She has the occasional drink.
Family history: Father died from complications related to ischaemic heart disease at 58. Her mother suffered a stroke at age 67 and lived in high care for her remaining 4 years.
Past medical/ surgical history: She has been admitted to hospital for treatment of lower respiratory tract infection (LRTI) twice in the last year. The patient has recently commenced on a low dose thiazide diuretic for hypertension. The patient denies any other history of cardiovascular disease, diabetes or hypercholesterolaemia.
Vital Signs:
• Respiratory rate 28 breaths per minute
• Sp02 90% on 3L via nasal prongs
• Heart rate is 90 beats per minute
• Blood pressure is 150/ 83 mm Hg
• Temperature is 37.9°C

Systems review
Neurological: GCS is 14/15 with pupils equal and reactive to light (PEARL).
Respiratory Inspection: The patient is sitting forward, using accessory muscles; she has a moist cough and is coughing regularly. The patient appears to be in respiratory distress. There are no abnormal thoracic landmarks or scars. You note an abnormal breathing pattern of tachypnoea and moist cough.
Palpation: Chest expansion is symmetrical and there is no tracheal deviation. There is limited mobility of the diaphragm and diminished vocal fremitus. There is no tenderness, lumps or lesions on the thorax.
Percussion: Dull sounds can be heard over lower lung fields.
Auscultation: There is air entry into all lung fields, however diminished in the lower bases. Bronchovesicular breath sounds can be heard with an I:E (Inspiratory/expiratory) ratio of 1:2. Coarse crackles can be auscultated on inspiration and a wheeze is present on expiration.
Cardiovascular Inspection: The patient is centrally pink; however peripheral cyanosis is present without clubbing.
Palpation: Peripheral pulses are palpable at +1. Calves are soft and non-tender. Jugular venous pressure (JVP) is less than 4cm.
Auscultation: Heart sounds of S1 & S2 are heard. There is no murmur.
An ECG confirmed sinus tachycardia and a portable chest radiograph showed shading in lower Left lung fields, with evidence of pneumonia. An arterial blood gas shows a pH 7.30, Pa02 68 mm Hg, PCO2 58 mm Hg, HCO3 27 mEq/L, and Lactate 2.1 mm Hg. Spirometry results include FEV1/FVC (ratio of forced expiratory volume in 1 second over forced vital capacity) of 62%.

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Case Study 2:

Presenting Complaint:
4 year old male [Ryan] presents with difficulty breathing. Mum states child has been tired in the last week and irritable. Noticed red rash on hands two days ago thought it was a reaction to grass as child had been spending a lot of time outside recently; itching profusely today with lack of sleep child has started to stress. Coughing started 1hr ago mum gave 12xpuffs Ventolin with no relief.
Past history:
-Asthma with previous ICU admission when he was three.
-Vaccinations up to date
Vital signs:
-BP 110/72
-HR 143
-O2 Sats 92% on RA
-Temp 37.3
-Resps 34

Systems review

NEUROLOGICAL: GCS is 14/15 with pupils equal and reactive to light (PEARL), varies between sleepy and unsettled.
RESPIRATORY Inspection: child is slightly distressed, speaking in short sentences, moderate intercostal recession.
Palpation: Chest expansion is symmetrical and there is slight tracheal deviation. There is no tenderness, lumps or lesions on the thorax.
Percussion: Resonance over all lung fields
Auscultation: There is equal air entry into all lung fields. Bronchovesicular breath sounds can be heard with an I:E (Inspiratory/expiratory) ratio of 1:2. Slight wheeze is present on expiration.
CARDIOVASCULAR Inspection: The patient is pale; slight peripheral cyanosis is present.
Auscultation: Heart sounds of S1 & S2 are heard. There is no murmur.
Chest radiograph showed clear lung fields.
INTEGUMENTARY: inspection Non-blanching purple spots over torso, blanchable raised red rash over hands-itchy.

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Chief complaint: The 48 year old male explains they have a six month history of intermittent back pain. The pain has been mainly around his lower back area, at times radiates to shoulders. He describes the pain as a dull throb which at times gives him a sense of dread. The pain may last for a few hours or ease on rest. He also describes an increase of epigastric pain over the past few months, which he believes to be heartburn and takes over the counter antacids when required. He presented to the ED as the pain was more severe and prolonged, was radiating down his back and associated with nausea. He has noted trouble passing urine at times.
Personal history: The patient is a 48 year old married administration officer. He exercises occasionally; he has gained weight in the last six months. He has 2 dependent children and his wife works as child care assistance. He tells you that he has an alcohol intake of 1-2 standards drinks per day and occasionally binge drinks on the weekend.
Family history: The patients’ father suffers from peripheral neuropathy and is medicated for hypertension. His mother had a cholecystectomy due to gall stones, a hysterectomy for cervical cancer and is taking medication for high cholesterol.
Past medical/ surgical history: The patient had a R knee arthroscopy in 2011. 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

Systems review

NEUROLOGICAL: GCS is 15/15 with pupils equal and reactive to light (PEARL).
RESPIRATORY Inspection: The patient displays comfortable breathing, nil cough. There are no abnormal thoracic landmarks or scars.
Palpation: Chest expansion is symmetrical. There is slight tenderness on lower midline area.
Percussion: Lung fields clear, resonant sounds.
Auscultation: There is air entry into all lung fields. Fine crackles can be auscultated on inspiration.
CARDIOVASCULAR Inspection: The patient is centrally pink; however lower limb peripheral blanching is present.
Palpation: Peripheral pulses are palpable at +1. Calves are soft and non-tender. Jugular venous pressure (JVP) is less than 4cm. Palpable abdominal pulse present.
Auscultation: Heart sounds of S1 & S2 are heard. There is no murmur.
An ECG confirmed sinus tachycardia and a portable chest radiograph showed shading in lower Left lung fields and midline area.
An arterial blood gas shows a pH 7.30, Pa02 78 mm Hg, PCO2 58 mm Hg, HCO3 27 mEq/L, and Lactate 2.1 mm Hg. Spirometry results include FEV1/FVC of 75%.

ABDOMINAL Inspection: The patient is sitting up, signs of distress with pained facial expression. Skin is pink and warm, patient is sweating. Abdomen not distended visible pulsations midline. No bruising, striae, surgical scares or lesions. The abdominal wall is moving symmetrically with respirations. The flanks are clear of bulges. No evidence of Cullen’s sign and Grey Turner’s sign.
Auscultation: Bowel sounds are minimally present and bruits heard midline.
Palpation: The patient has moderate midline and back pain, increases when lying flat. No crepitus, rigidity, rebound tenderness, referred tenderness, or masses palpated. During deep palpation tenderness over the midline region is noted.
Percussion: Abdomen is resonant to percuss.

Case Study 4

Presentation: 68 year old man (Eddie) presents to ED via QAS from fall at home. Eddie was found on the floor by paramedics after pressing his vita-call button. His speech was slurred on scene and his breath smelt acidic. On arrival, Eddie’s GCS was 14 and was verbally abusive to paramedics. 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’. Eddie lives alone in an aged care retirement community.
Personal History: Eddie is a retired boiler maker with 4 children all over the age of 40. Eddie admits to being generally healthly ‘apart from the occasional flu’. Eddie states that he has been a little more tired these days but seems to think that is because he no longer goes to art class in the village and has slowed down on his daily walk because his left knee is ‘starting to cause him grief’. Eddie admits to indulging in a few drinks lately because his friends don’t talk to him anymore and his children are too busy.
Family History: Father died of bowel obstruction leading to septicaemia at 85. Mother medication history of diabetes, 23 surgeries throughout her life-artificial arteries in upper extremities and legs due to atherosclerosis.
Medical History: History of angina, hypertension, GORD, appendectomy at age 13. Eddie admits to recently being started on Tramadol for his knee pain which is currently under investigation by his local GP.
He is on a range of medications:
Anginine prn, Metoprolol 50mg BD, aspirin 100mg OD, Atorvastatin 40mg Nocte, Esomeprazole 40 mg BD, mylanta PO, Pulmicort Turbuhaler 400mcg BD, Ventolin 2 puffs prn, panadeine forte 2 tabs prn, Zoloft 50mg mane. Lasix 40mg BD. Blackmores Glucosamine tablets 1500mg OD.
VITAL SIGNS:
• Respiratory Rate: 22
• Blood Pressure: 168/97
• Temperature: 36.5
• Heart Rate: 107
• SP 02: 95% on RA

Systems Review

NEUROLOGICAL: GCS is 14/15 with pupils equal and reactive to light (PEARL). Patient is confused at times and verbally abusive. Contusion to back of his head.
RESPIRATORY Inspection: The patient displays comfortable breathing, slight cough. There are no abnormal thoracic landmarks or scars.
Palpation: Chest expansion is symmetrical.
Percussion: Lung fields clear, resonant sounds.
Auscultation: There is air entry into all lung fields. Fine crackles can be auscultated on inspiration.
CARDIOVASCULAR: Inspection: The patient is centrally pink.
Palpation: Peripheral pulses are palpable at +3. Calves are soft and non-tender.
Auscultation: Heart sounds of S1 & S2 are heard. Irregular heart beat noted.
An ECG shows atrial fibrillation and a portable chest radiograph showed clear lung fields.
An arterial blood gas shows a pH 7.30, Pa02 78 mm Hg, PCO2 58 mm Hg, HCO3 27 mEq/L, and Lactate 2.1 mm Hg. Spirometry results include FEV1/FVC of 75%.
Electrolytes Na 140, K 4.3, CL 100, HCO3 22, GLU 8.1, Urea 4.4, Creat 0.06
ABDOMINAL Inspection: The patient is sitting up, nil distress. Skin is pink and warm. Abdomen not distended. No bruising, striae, surgical scares or lesions. The abdominal wall is moving symmetrically with respirations. Bowels not opened regularly
Auscultation: Bowel sounds are present.
Percussion: Abdomen is resonant to percuss.
Palpitation: slight tenderness lower abdomen