NRNP 6550 Week 6 i-Human Case Study Tom Bradford
- $20.00
Document Preview
NRNP6550wk6Ihuman: Tom Bradford
Admission Orders (do not write an explanation of the order(s), ONLY the order)
1. DX: (1) primary dx (2) secondary “relevant” dx
2. Admit to: , stable/unstable/critical/etc., Dr. “you pick the name”, call upon arrival with rm #
3. Isolation/Precautions:
4. Allergies:
5. Diet:
6. Activity:
7. IV: how many? SL
8. IVF:
9. LABS: only what you need done upon arrival (not a repeat of prev. ordered meds)
10. AM LABS:
11. RADS (US, CT, XRAYs)/Diagnostic tests:
12. PT/OT/Nutrition/SW/Pysch/etc. Consults?
13. Consult: Specialty services
14. Screening (s): HIV, TB, PNA vaccine, flu shots, etc.
15. Medications:
• Medication (full instructions, no nicknames) and END date
• Medication
• Medication
Plan Rationale and Supporting Documentation
1. DX: why?
2. Admit to , why?
3. 3. Isolation/Precautions, why?
4. Allergies: no rationale/sup. Documentation needed
History
Tom Bradford 71-year-old 6’0 180 BMI: 24.4 Normal severe sharp abdominal pain for the past four hours not radiating history of smoking hx of HTN Afib on aspirin at times metoprolol Lisinopril Provoking: ate oatmeal Does not follow regular diet nausea and vomiting 1 loose stool
Assessment
mild tenderness to palpation Afib
Irregular pulse rate T:97.9
P:120 R:24 BP:119/64
HPI: 125 words
Tom Bradford is a 71-year-old male patient who presented with an acute onset of severe abdominal pain for the past four hours. He described his pain as sharp and non-radiating with the severity of 10/10 and reported that his symptoms started after eating oatmeal for breakfast.
Associated symptoms include one episode of loose stool, nausea, and vomiting with shortness of breath and palpitations. The patient is a chronic smoker for the past 50 years, and his medical history includes hypertension, CAD and atrial fibrillation status post cardioversion. He has no known allergies and is currently taking Metoprolol, Lisinopril, and Aspirin. Clinical findings during physical examination revealed tachypnea, tachycardia with irregularly heart rhythm, mild diffuse abdominal tenderness and positive stool for occult blood….. Continue
