RAPID Reasoning Case Study-STUDENT
I.Data Collection
History of Present Problem:
Mike Kelly is a 51 year old Caucasian male. He is 6 feet tall and weighs 275 pounds (BMI
37.3) with an abnormal distribution of weight around his abdomen. He does not regularly exercise, does
not like to cook, and eats fast food 3-5x during the week. He has smoked 1 pack per day since the age of
20 (31 pack years). He has no current diagnosed medical problems. He becomes concerned and came to
the urgent care facility today because he is more easily fatigued and has a headache for the past 3 days
that has not improved. He didn’t go to work today and that is not typical for Mike.
Personal/Social History:
Mike is self-employed and owns his own auto mechanic business. He currently has no health
insurance. His father had hypertension and died of a myocardial infarction (MI) at the age of 50.
Angelina, his wife, came with him to urgent care and shares that he is usually stoic with health problems
so this must really bother him or he is afraid. He took Excedrin and Motrin for pain and it didn’t help that
she gave him a dose of Castor oil since she is from Puerto Rico and that is the first thing they do for any
illness in her country of origin.
What data from the histories is important & RELEVANT; therefore it has clinical significance to the
nurse?
RELEVANT Data from Present Problem: Clinical Significance:
-more easily fatigued Etiology of essential hypertension (Ignatavicius
-headache for past 3 days 710) Includes:
-BMI of 37.3 -smoking
-fast food eaten 3-5x per week -excessive intake of sodium
-smoker for the past 31 years -obesity
-does not regularly exercise -physical inactivity
-self employed -high stress
RELEVANT Data from Social History: Clinical Significance:
-father has medical history of hypertension -family history puts him at a greater risk for a heart
and MI attack
-took Excedrin, Motrin, and castor oil before - Excedrin is a combo of Tylenol, aspirin, and
coming in caffeine (Caffeine can create tachycardia)
-Castor oil relieves pain and promotes healing
used culturally, more useful for open wounds
-Motrin is a NSAID as well that thins the blood
(Prescription)
II. Patient Care Begins:
1
, Current VS: WILDA Pain Scale (5th VS)
T: 98.9 (oral) Words: Ache
2
I.Data Collection
History of Present Problem:
Mike Kelly is a 51 year old Caucasian male. He is 6 feet tall and weighs 275 pounds (BMI
37.3) with an abnormal distribution of weight around his abdomen. He does not regularly exercise, does
not like to cook, and eats fast food 3-5x during the week. He has smoked 1 pack per day since the age of
20 (31 pack years). He has no current diagnosed medical problems. He becomes concerned and came to
the urgent care facility today because he is more easily fatigued and has a headache for the past 3 days
that has not improved. He didn’t go to work today and that is not typical for Mike.
Personal/Social History:
Mike is self-employed and owns his own auto mechanic business. He currently has no health
insurance. His father had hypertension and died of a myocardial infarction (MI) at the age of 50.
Angelina, his wife, came with him to urgent care and shares that he is usually stoic with health problems
so this must really bother him or he is afraid. He took Excedrin and Motrin for pain and it didn’t help that
she gave him a dose of Castor oil since she is from Puerto Rico and that is the first thing they do for any
illness in her country of origin.
What data from the histories is important & RELEVANT; therefore it has clinical significance to the
nurse?
RELEVANT Data from Present Problem: Clinical Significance:
-more easily fatigued Etiology of essential hypertension (Ignatavicius
-headache for past 3 days 710) Includes:
-BMI of 37.3 -smoking
-fast food eaten 3-5x per week -excessive intake of sodium
-smoker for the past 31 years -obesity
-does not regularly exercise -physical inactivity
-self employed -high stress
RELEVANT Data from Social History: Clinical Significance:
-father has medical history of hypertension -family history puts him at a greater risk for a heart
and MI attack
-took Excedrin, Motrin, and castor oil before - Excedrin is a combo of Tylenol, aspirin, and
coming in caffeine (Caffeine can create tachycardia)
-Castor oil relieves pain and promotes healing
used culturally, more useful for open wounds
-Motrin is a NSAID as well that thins the blood
(Prescription)
II. Patient Care Begins:
1
, Current VS: WILDA Pain Scale (5th VS)
T: 98.9 (oral) Words: Ache
2
