Michael Case Study - Patient Medical History - Nursing Assignment Help

Assignment Task :

CASE STUDY

Michael Kwon is an 82-year-old male. He was admitted to the Emergency Department (ED) of a General Hospital at 1030 hrs after he had experienced sharp central chest pain, which lasted for about 10 minutes while he was at his home. Mr Kwon claimed that he felt “light-headed” during the chest pain and fell heavily onto the sharp edges of a natural Jarrah wood table in his living room.  He lacerated his right leg and there was ‘lots of bleeding.’ His wife Gloria applied first aid and called the ambulance. Mr Kwon claimed that he also “fell onto the ground and complained of pain 5 out of 10 at rest, on his right lower ribs.”

When the Ambulance Officers attend to Michael, Gloria claimed, “I think Michael hit his head and he is complaining that his neck is sore.” The Ambulance Officers assessed Mr Kwon and provided interventions.  A neck collar was placed insitu, his right leg was elevated and a pressure dressing was applied. After that, the ambulance officers liaised with the hospital ED Medical Officer (MO) and reported the findings. The MO ordered sublingual Anginine half tablet for chest pain, soluble Aspirin 300mg oral and oxygen via nasal prongs. Mr Kwon was transferred via ambulance to the hospital.

On initial assessment by the ED nursing staff, Mr Kwon was slightly drowsy and only responded to voice. His voice was hoarse, harsh and high-pitched. His breathing was shallow, with occasional dyspnoea on movement. Michael displayed asymmetrical chest movements on the right side. On anterior auscultation of his lungs, whilst he was sitting up, his lung fields demonstrated a bilateral wheeze with reduced air entry on his right lower lung field. The colour of Michael’s skin was pink to pale with some mild spotty urticarial rash on his chest. 

Mr Kwon's pulse was irregular, weak and rapid. The ED clinical staff note that Michael’s peripheries are cool and clammy with a pale appearance. The lead II ECG monitor indicates sinus tachycardia with some ST elevation. Mr Kwon complained that his skin “is feeling a little itchy”.  The Medical Officer inserted an intravenous cannula and also took blood samples for laboratory testing. Michael claimed he had been “nauseous overnight, had vomited once and had very little to drink overnight and this morning.” 

Mr Kwon was slightly drowsy and opened his eyes to speech. Michael was orientated to time place and person obeyed commands and had equal normal power in both arms, normal strength in his left leg and mild weakness in his right leg. His pupils were equal 3 mm and reacted to light. His GCS was 14. The ED Nurse decided that Mr Kwon was for senior medical review within 10 minutes. 

Mr Kwons past medical history and surgical history include; hypertension for 10 years and he was diagnosed one month ago with stage one chronic renal failure. Michael has osteoarthritis of his neck, lower back, and both hips, and he had an inguinal hernia repair in his twenties.  Mr Kwons weight was 102 kg and his height was 186 cms. Allergies include milk, shellfish and Ibuprofen. 

1. Describe the Patient Medical History

1. Reason for hospital admission (including the pathophysiology of admitting diseases)

2. Describe the rationale for the most relevant diagnostic tests (blood tests, X-ray, ECG, CT Scans, MRI etc., 5 Max).

2. Nursing Care

Evaluate and review relevant RPH Nursing Practice Standards and Clinical Practice Standards and compare to the case study. Form an impression and highlight the main targeted issues in the case study including:  

• Describe patient abnormalities and instability and apply hospital standards.  

• Identify errors in the case study and describe your interpretations. 

• Are any clinical assessments, interventions or standards omitted in the case study? Discuss this in your submission. 

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