Question Answered step-by-step MAKE A NURSES NOTES CHARTING IN EACH CASE STUDY Case study # 1 A… MAKE A NURSES NOTES CHARTING IN EACH CASE STUDYCase study # 1 A 38years old female, pregnant 3 wks, presented in the ER vomiting 4-6 times approx 100 ml in amt of previously ingested food for the past 2 day. VS upon admission: 124/83, temp 36.8 ax,  PR 102, 23. Denies pain. O2 sat at 98% room air. No known allergy.With com-morbidities: stage 1 HTN, borderline DM. Height 4’11, ABW= 156lbs.Alert, oriented x4, conversant. Wears reading glasses. Denies HOH. Lungs clear. With even non laboured breathing.Denies SOB. ABD globular, soft, non tender. Urinated x4 since admission approx 180ml per voiding.  Denies dysuria and urinary retention. Able to move all extremities without any difficulty. No deems notes. On IVF PNSS 1 liter at 125ml per hr as prescribed. Current meds: Prenatal vitamins 1 PO dailyLabs: CBC, serum basic metabolic panel, hba1c, serum creatinine, serum, serum liver function testCase study #2A 16 yrs old male nursing student was admitted with chief complaint of coughing and fever for the past 1wk. VS upon admission 110/73, 38.6 oral, 110, 24, c/o generalized discomfort 2/10. With known allergy to peanuts, verbalized hives as reaction. With course rales at both lung fields,  with wheezing right upper anterior lung field, with noted lagging at R side. With productive cough and light greenish sputum moderate in amt. With slight SOB,  O2 sat at 92% at room air. No pallor notes.ABD round soft non tender. With hypo active BS X 4. Last BM Jan 29, 2020 to small ant soft light brown stool. Urinated 5x since admission approx 250ml per urination. Able to move extremities without any difficulty nor pain. No edema noted.Admitting RX:1.  Sputum C & S2.  Test for NCov3.  Droplet precaution4.   CXR5.   IVF PNSS one liter at 100ml per hr 6.   Start on azithromycin 500 mg PO daily x5 days post spuctum C & S7.   Zinc 30 mg po daily8.  DAT as toleratedCase study #3A 5 years old female with chief complaint  of colds, ear ache and fever. VS upon admission 100/60, 39 ax, 104, 26. C/o of 4-6 on the pain face scale. No known allergies. With clear nasal drainage. Denies SOB. Both lung fields clear, Both ears slight reddish,  non- edematous, no active drainage, non foul, tender to touch. ABD soft, normoactive BS x4. Last BM Jan 31, 2020 large ant soft light green stool. Urinated 2x since sdmission approx 150 ml per voiding. Able to move all extremities without difficulty.Admitting RX1.Amoxicillin 125ng PO q 12 hrs for 10 days2.Pedia Zinc 5ml PO daily3.CBCCase study #4An 18 years old male sports mgt student with chief complaint constantly headache and dizziness. VS upon admission 160/92, 36, 102, 20. C/o 10/10 pain at fronto-parietal part. O2 sat at 98% at room air. No known allergy . ABW 165lbs, Height 5’2. C/O occasional dizziness. Denies vertigo. No nystagmus nor strabismus. PERRLA. C/o occasional nausea but no vomiting. Alert oriented x4. Conversant. GCS= 15. Both lung fields clear, with even non labored respiration. ABD soft with normoactive BS x4 . Last BM Jan 31, 2020 large brown well formed stool. Able to move all extremities without difficulty. Negative Romberg test.1.Serum Basic metabolic panel2.CBC3.Serum lipid panel 4.Serum creatinine, liver panel5.Cranial CT with n without contrast 6.VS q 1hr, Neuro  check q hr7.Start amlodipine 5mg PO daily8.Perindropril 10mg PO dailyCase study #5A 9yrs  old female student with chief complaint of diarrhea for the past 3 days. VS 98/74 , 37.7 oral, 74, 20. C/o occasional 3/10 ABD pain. Both lung fields clear. Denies SOB. Hyperactive BS both lower quadrarnts. Had 10 episodes of liquid green watery stool approximately 150 per episode since admission. With dry lips, dry skin. ABD protuberant, soft Mother stated that patient ate raw foods in a party few days ago. GCS 15. Able to move al extremities but Weak. Urinated x2 since admission to dark yellow approximately 50 ml per voiding. Her mother stated that little girl was able to drink 200ml of pedialyte prior to admission.MD RX1.IVF PNSS 1 liter at 100ml/hr2.Erceflora 1 nebule PO QID 3.DAT4.Stool Exam5.Pedia Zinc 5ml PO daily 6.Metronidazole 125mg IV every 12 hrs for 10 days7.Enteric precaution8.CBC9.Serum basic Chemistry profile Health Science Science Nursing NURSING 493 Share QuestionEmailCopy link Comments (0)

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