Four Days of Nausea, Vomiting and Fever

What is most important in this case study in which an older Vietnamese woman presents to the ER with fever, nausea and vomiting?

Updated:  

This article was reviewed and fact-checked by our Editorial Team.
Four Days of Nausea, Vomiting and Fever

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

  • Losartan/HCTZ 100mg/12.5mg PO daily
  • Fenofibrate 160 mg PO daily
  • Metformin 500 mg PO 2x daily
  • Herbal preparation for HTN
  • Herbal medicine preparation to lower blood sugar and reduce blood pressure taken daily
  • Day nhan long tea for fever

Allergies

NKA

Vital Signs

  • BP 171/97 sitting, RA
  • HR 107
  • RR 26
  • T 102o F
  • SpO2 95% RA
  • HT 5'
  • WT 160 lbs

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.

5
Up Vote Up Vote ×
SafetyNurse1968

About SafetyNurse1968, BSN, MSN, PhD

Patient Safety Columnist / Educator

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.

60 Articles   529 Posts

Share this post

Share on other sites
Specializes in NICU.

What is her baseline mental status? What are those herbal medicines? I also want to know electrolyte levels since she has poor intake with N/V. And a UA and culture

7
Up Vote Up Vote ×
Specializes in Public Health, TB.

CBC to check white count (viral vs. bacterial infection]; CMP to check electrolytes, kidney function, glucose, osmolality, and liver function. 

Assess for any pain: chest pain, on inspiration, HA, abdominal, flank, pain on movement., events around onset: ingested food, exposure to anyone who was ill, etc. Any recent injuries that may have pierced skin? Any unusual rashes (could point to source of infection]. Lungs and heart sounds, skin color, seems like skin is likely tented. 

And yes, UA and cx. Any GI symptoms? if so, stool culture, O&P.  

 

4
Up Vote Up Vote ×
Specializes in Infusion Nursing, Home Health Infusion.

Yes I agree...we need a list of all herbal preparations taken and their amounts.Agree on getting all labs requested and get an immediate glucose level and get done blood cultures.I agree on finding out if the patient is in pain and of course, its type and location.

4
Up Vote Up Vote ×

Elevated temp can be sepsis so I want blood cultures. Increased respiration’s can be the onset of shock- so I want IV fluids. N&V, leg pain can be hypo kalemia is so I want electrolyte panel CBC/bmp. Also an ekg to see if cardiac output had been affected. I would also start IV ABT pprophylactic after labs and blood cultures are a initiated. Also good head to toes for infection sources

6
Up Vote Up Vote ×
Specializes in ED, Tele, MedSurg, ADN, Outpatient, LTC, Peds.

Septic work up including cbc,bmp,pt/ptt and type and screen, blood cultures, urine analysis and C/S, CXR,EKG and antipyretics  and fluids till we figure out what's causing the fever. Do you have any results back? Keep her NPO for now.

4
Up Vote Up Vote ×
Specializes in Education, Informatics, Patient Safety.

FIRST FOLLOW UP POST:

Excellent observations and questions – thank you for the rationale!

Here are the medicines she is taking: bitter melon (Momordica charantia), often called bitter gourd (kho qua in Vietnamese), tea from guava leaves (Psidium guayava, Vietnamese la oi)

In an ethnographic study of 40 Vietnamese patients being treated for diabetes, a strong aversion to insulin therapy was reported. Ideas about cause and proper treatment were strongly related to culture. Almost 2/3 had used traditional home remedies for diabetes. This points to a need for culturally appropriate education about TII diabetes and modern therapy for the disease.

(Vietnamese diabetic patients and their physicians: what ethnography can teach us: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071603/)

The patient does not report any pain, no chest pain, no inspiratory pain etc…The family states they can recall nothing unusual (foods, exposures, injuries etc.) happening around the time their mother began having symptoms.

Review of Systems: only abnormal values presented so digestive & respiratory are WNL

  • LOC: A&Ox2, not oriented to time (she is normally “quite sharp” according to her family)
  • HEENT: Fruity odor upon exhalation
  • Skin: poor skin turgor, dry, cracked skin around mouth, 10 dark red circles on back, 25 cm in diameter.
  • CV: capillary refill 4 seconds
  • Musculoskeletal: unsteady gait, unable to ambulate without assistance
  • Neuro: bilateral peripheral neuropathy in lower extremities

Laboratory Test Results:

  • Na 149 meg/L (135-145)
  • K 4.8 meq/L (3.5-5)
  • Cl 107 (101-112)
  • HCO3 30 mg/dL (22-32)
  • BUN 10 mg/dL (8-20)
  • Cr 0.7 mg/dL (0.6-1.2)
  • Serum osmolality 300 mOsm/kg (275-295)
  • Anion Gap 15 mEq/L (6-12)
  • Serum ketones 3.1 mmol/L (<1.5)
  • BNP 32 pg/ml (<100 pg/mL)
  • Serum Glucose 585 mg/dL (60-110)
  • A1C: 12.1% (3.9-6.9)
  • Ca 9.1 mh/dL (8.5-10.5)
  • TSH 4.7 uU/mL (0.4-6)
  • FT4 20 pmol/L (9-24)
  • PTH 45 pg/mL (11-54)
  • Hb 12.3 g/dL females (12-15.5)
  • Hct 37.5% females (35-45%)
  • Plt 230,000 cu/mm (150,000-450,000)
  • WBC 9.0 x 103/mm3 (4,800- 10,800)

 

ABGs:

  • PaCO2 40mmHg (32-48)
  • HCO3/Bicarbonate 22 (22-28mmol/L)
  • PaO2 95 (83-108)
  • pH 7.34 (7.35-7.45)

Urinalysis

  • Urine is dark with a strong odor
  • pH 6.2 (7.35-7.45)
  • Specific gravity 1.034 (1.016-1.022)
  • Positive for ketones and glucose
  • Positive for bacteria

Culture and sensitivity: Negative after three days

COVID-19 PCR test: negative

Chest X-ray: clear

EKG: normal

3
Up Vote Up Vote ×
Specializes in Education, Informatics, Patient Safety.

Please don’t leave your diagnosis here- post it in admin. The responses are for questions and for sharing your nurse brain with new nurses/students. What assessment details are most important and why? What is your priority intervention and why? Thanks!

2
Up Vote Up Vote ×
Specializes in NICU.

What is PaO2 on ABG?

1
Up Vote Up Vote ×
Specializes in Education, Informatics, Patient Safety.
38 minutes ago, KRVRN said:

What is PaO2 on ABG?

Check comments for FIRST RESPONSE 

1
Up Vote Up Vote ×
Specializes in Education, Informatics, Patient Safety.

My apologies, the PaO2 is supposed to be 95!

1 hour ago, SafetyNurse1968 said:

Check comments for FIRST RESPONSE 

PaO2 is 95, somehow it got deleted by the computer gremlins

2
Up Vote Up Vote ×
Specializes in Education, FP, LNC, Forensics, ED, OB.

We have had several replies in the ADMIN HELP DESK.

Be sure to get your "guess at the dx" documented. This Case Study will be concluded very soon.

Up Vote Up Vote ×
+ Add a Comment