This article was reviewed and fact-checked by our Editorial Team.
- Community
-
Programs
- Schools
-
Careers
- RN Specialties
- Best RN Jobs and Salaries
- Aesthetic Nurse
- Nursing Informatics
- Nurse Case Manager
- NICU Nurse
- Forensic Nurse
- Labor and Delivery Nurse
- Psychiatric Nurse
- Pediatric Nurse
- Travel Nurse
- Telemetry Nurse
- Dermatology Nurse
- Nurse Practitioner
- Best NP Jobs and Salaries
- Family NP (FNP)
- Pediatric NP
- Neonatal NP
- Oncology NP
- Acute Care NP
- Aesthetic NP
- Women's Health NP
- Adult-Gerontology NP
- Orthopedic NP
- Emergency NP
- Psychiatric-Mental Health NP (PMHNP)
- APRN
- Nurse Educator
- Nurse Administrator
- Certified Nurse Midwife (CNM)
- Clinical Nurse Specialist (CNS)
- Certified Registered Nurse Anesthetist (CRNA)
- Resources
- Education
Chief Complaint:
Provided by caregiver: "My grandfather is confused and pretty sick. He was up most of the night coughing.”
History of Present Illness:
H.T. is an 82-year-old Hispanic male who is widowed and a retired grocery store owner. His 28-year-old granddaughter lives with him. He uses a walker and takes daily walks in the neighborhood with her. He can perform most ADLs, but his granddaughter prepares his meals. He presents to the clinic with his caregiver who reports that about a week ago, Mr. T. came down with a cold and had a runny, stuffy nose. He visited the curandero and has been drinking gordolobo tea with honey, lemon and a generous dollop of tequila. He appeared to be getting better, but then several days ago he developed a cough. Over the last two days, the cough has become worse and he can't seem to catch his breath. He was confused last night and nearly fell getting out of bed.
General Appearance:
The patient's age is consistent with that reported. He is well-groomed and neat, uses a walker for ambulation and walks with a pronounced limp. He is lethargic, frail and thin oriented to self only. Patient is coughing and using accessory muscles to breathe. Appears uncomfortable and in moderate respiratory distress.
Past Medical History:
Family History:
(+) for HTN and cancer, (-) for CAD, asthma, DM
Social History:
Medications:
Allergies:
Penicillin (rash)
Okay, super sleuths, what are all the possible reasons for a cough? What's causing his confusion? I think the most fun way to play is to imagine you only get 5 questions. With that limit in mind, what information could you ask for that would give you the most information for a diagnosis? What labs do you want? What other diagnostic tests should we run? Ask me some questions!
DISCLAIMER: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.
About SafetyNurse1968, BSN, MSN, PhD
Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com.
Share this post
Share on other sites