NURS8747 Assignment 2: Clinical vignette

NURS8747 Assignment 2: Clinical vignette Case Study

72 year-old female complaining of flu like symptoms, including malaise, loss of appetite, recent 3kg weight loss, fever (38.4 38.5’C) and dry cough presented to the Emergency
Department.
Today she has become increasingly irritable and her husband states in the last two hours she has become confused. She also started complaining of abdominal pain and nausea, so he decided to bring her to hospital.
Past medical history (PMH): Diabetes type 2, hypertension, hypercholesterolaemia.

Routine medications: Gliclazide MR 120mg mane, Metformin XR 2g nocte, Cardizem, Cartia. She stopped taking Gliclazide and Metformin one month ago, since she felt they made her stomach upset. She was also convinced that they made her blood glucose levels too low. She has not recently measured her BGL at home and her last HbA1c was 8.9% around 2 years ago. Her husband states that she has been urinating a lot lately.

Assessment: eyes 4/4, Voice 4/5, Motor 6/6 GCS 14/15. Full power in all limbs. PEARL 4 mm.

Chest clear, non-productive cough. RR 20 with deep respiration.

Blood pressure 100/70mmHg, p. 90 and regular.

Abdo – soft, nil tenderness, bowel sounds present.

Integument: Flushed dry skin and mucus membranes, decreased skin turgor, varicose veins to leg and left heel ulcer. Husband states she stepped on something in the garden about a month ago and difficult to heal. Bilateral pitting oedema, left slightly greater than right leg.

Urinalysis: PH 8, SG 1.35, protein ++, glucose +++, Ketone neg, RBC +, bilirubin neg, WBC+, Plan: Full bloods, chest x-ray, culture blood, culture urine and swab culture of left heel wound.

IVT 84ml/hour 4?xtrose1/5N/Saline, review by endocrinologist, monitor BGLs 4/24. Wound management.

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