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
70 y/o Asian American female is brought to the Emergency room by her spouse and daughter with nausea and vomiting. The daughter states, "Her fever has been over 102°F for the last few days and she won't eat or drink or take her medications and she is very confused. She keeps telling me to get my sister, but she died five years ago.”
History of Present Illness
N/V for 4 days, fever over 102 for 2 days. Negative COVID-19 PCR test 1 day ago.
General Appearance
Patient is well groomed and appears stated ethnicity and age. Patient is obese with wrinkled skin. She is lethargic and her eyes are half open. She mumbles continuously to her daughter and husband in Vietnamese.
Past Medical History
Smoker ½ ppd for 40 years, Diabetes Mellitus Type II 2 years; Coronary Artery Disease 5 years; Hypertension 10 years; Hypercholesterolemia 5 years; recent onset of bilateral lower extremity neuropathy.
Family History
Father died of liver cancer at age 70, Mother died of pulmonary fibrosis at age 78. Patient has three children, one son age 40 with no medical issues. Daughter age 38 is overweight and pre-diabetic. Another daughter died in a car accident 10 years ago at the age of 25.
Social History
Patient is Vietnamese. She moved to the U.S. 45 years ago with her husband. They owned a sewing machine repair shop before retiring 5 years ago. The patient and her husband speak very little English.
Medications
Allergies
NKA
Vital Signs
Ask me questions, but when you do, please tell me why you want the information. Experienced nurses – what information do you see that is most important? What do you want to do first? Tell us why. It's important for students and new nurses to learn what goes on inside your head!
For example, you might say, "I want lab values because I think she might have an infection. The high fever, the elevated BP, the decreased orientation – all are signs she might have an infection of some kind.” Give us insight into what clues or cues are telling you what is wrong.
You can also respond by anticipating orders. Give me a list of what you think the HCP might order and why. Do you anticipate a culture and sensitivity test? If so, why?
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