NR283-Case IStudy I1 IFluid-Electrolyte IAcid-base IBalance
Case Istudy I1
Mr. IWilliams Iis IaI69 Iyear Iold ImaleIwho Iarrived Iat Ithe Iemergency Idepartment, Icomplaining IofIs evere
I vomiting I & I weakness I for I two I days.
Identifying IInformation:
69yr Iold Imale
History Iof IPresent IIllness:
69 Iyr Iold Imale Ipresented Ito Ithe IED Ic/o Iof Isevere Ivomiting I& Iweakness Ifor Itwo Idays. IHe Istates
I he I has I taken I the I medications I for I vomiting I but I can’t I hold I anything I down. I He I feels I dizzy I when
I standing I up Iand I feels I very I weak. ICurrently I being I treated Ifor I tongue Icancer. I HeI is I on I cycle I 3/5
I ofIchemotherapy I & I radiation.
Past IMedicalIHistory:
HypertensionI
Gout
Past ISurgical IHistory:
Surgical Iresection-base Iof Itongue
Current IMedications:
● Lisinopril-hypertension
● Colchicine-gout
● Ondansetron-nausea
● Chemotherapy Icombined Iwith Iradiation Ix7days-every Iother Iweek IforI5 Iweeks
o 5-fluorouracil I(5-FU)
o Cisplatin
● Hydroxurea
● Magic Imouthwash-stomatitis I& Imucositis
Allergies:
No Iallergies
Family IHistory:
Mother-deceased-breast Icancer, Ihypertension, IAlzheimer’s Idisease
I Father-deceased-CAD,Ihypertension, Imyocardial Iinfarction, Iheart
IfailureIS ocial IHistory:
Occupation: Iretired Iauto Ifactory
IworkerITobacco I Use: I everyday
Illicit IDrug IUse: Inever
I Alcohol I Use: I occasional I use
Review IofISystems: I(what Ipatient Itells Iyou)
Skin: Ipain I& Iitching Ito IfaceI& Ineck, Ino Ichanges Iin Ihair, Ino Ichanges Iwith Inails
Mental IHealth: Ino Icurrent Ifeelings Iof Isadness,Ino Isleep Idisturbances, Ino Isuicidal
I ideationsIN eurological: I+ I light-headedness, I + I dizziness, I + I paresthesia I to I feet I & I hands, I no
I balance I problems
Case Istudy I1
Mr. IWilliams Iis IaI69 Iyear Iold ImaleIwho Iarrived Iat Ithe Iemergency Idepartment, Icomplaining IofIs evere
I vomiting I & I weakness I for I two I days.
Identifying IInformation:
69yr Iold Imale
History Iof IPresent IIllness:
69 Iyr Iold Imale Ipresented Ito Ithe IED Ic/o Iof Isevere Ivomiting I& Iweakness Ifor Itwo Idays. IHe Istates
I he I has I taken I the I medications I for I vomiting I but I can’t I hold I anything I down. I He I feels I dizzy I when
I standing I up Iand I feels I very I weak. ICurrently I being I treated Ifor I tongue Icancer. I HeI is I on I cycle I 3/5
I ofIchemotherapy I & I radiation.
Past IMedicalIHistory:
HypertensionI
Gout
Past ISurgical IHistory:
Surgical Iresection-base Iof Itongue
Current IMedications:
● Lisinopril-hypertension
● Colchicine-gout
● Ondansetron-nausea
● Chemotherapy Icombined Iwith Iradiation Ix7days-every Iother Iweek IforI5 Iweeks
o 5-fluorouracil I(5-FU)
o Cisplatin
● Hydroxurea
● Magic Imouthwash-stomatitis I& Imucositis
Allergies:
No Iallergies
Family IHistory:
Mother-deceased-breast Icancer, Ihypertension, IAlzheimer’s Idisease
I Father-deceased-CAD,Ihypertension, Imyocardial Iinfarction, Iheart
IfailureIS ocial IHistory:
Occupation: Iretired Iauto Ifactory
IworkerITobacco I Use: I everyday
Illicit IDrug IUse: Inever
I Alcohol I Use: I occasional I use
Review IofISystems: I(what Ipatient Itells Iyou)
Skin: Ipain I& Iitching Ito IfaceI& Ineck, Ino Ichanges Iin Ihair, Ino Ichanges Iwith Inails
Mental IHealth: Ino Icurrent Ifeelings Iof Isadness,Ino Isleep Idisturbances, Ino Isuicidal
I ideationsIN eurological: I+ I light-headedness, I + I dizziness, I + I paresthesia I to I feet I & I hands, I no
I balance I problems
