NURS8747: Clinical Vignette - Medical Registrar Dr Bateman Case Study - Nursing Assignment Help

Assignment Task:

Admission note to HDU: Medical Registrar Dr. Bateman (4565)  

72-year-old female complaining of flu like symptoms, including malaise, loss of appetite, 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: Glibenclamide, Metformin, Cardizem, Cartia. She stopped  taking Glibenclamide and Metformin one month ago, since she felt they made her stomach upset. She was also convinced that they made her blood sugar 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 100/70, p. 90.  

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,  diabetic diet. Wound management. 

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