Parth Solanki
Case study 1
Mr. Williams is a 69 year old male who arrived at the emergency department, complaining of
severe vomiting & weakness for two days.
Identifying Information:
69yr old male
History of Present Illness:
69 yr old male presented to the ED c/o of severe vomiting & weakness for two days. He states
he has taken the medications for vomiting but can’t hold anything down. He feels dizzy when
standing up and feels very weak. Currently being treated for tongue cancer. He is on cycle 3/5 of
chemotherapy & radiation.
Past Medical History:
Hypertension
Gout
Past Surgical History:
Surgical resection-base of tongue
Current Medications:
● Lisinopril-hypertension
● Colchicine-gout
● Ondansetron-nausea
● Chemotherapy combined with radiation x7days-every other week for 5 weeks
o 5-fluorouracil (5-FU)
o Cisplatin
● Hydroxurea
● Magic mouthwash-stomatitis & mucositis
Allergies:
No allergies
Family History:
Mother-deceased-breast cancer, hypertension, Alzheimer’s disease
Father-deceased-CAD, hypertension, myocardial infarction, heart failure
Social History:
Occupation: retired auto factory worker
Tobacco Use: everyday
Illicit Drug Use: never
Alcohol Use: occasional use
Review of Systems: (what patient tells you)
Skin: pain & itching to face & neck, no changes in hair, no changes with nails
Mental Health: no current feelings of sadness, no sleep disturbances, no suicidal ideations
Neurological: + light-headedness, + dizziness, + paresthesia to feet & hands, no balance
problems
This study source was downloaded by 100000838234991 from CourseHero.com on 07-21-2022 14:08:05 GMT -05:00
https://www.coursehero.com/file/48215805/NR283-Case-Study-1-Fluid-Electrolyte-Acid-base-Balancedocx/
Case study 1
Mr. Williams is a 69 year old male who arrived at the emergency department, complaining of
severe vomiting & weakness for two days.
Identifying Information:
69yr old male
History of Present Illness:
69 yr old male presented to the ED c/o of severe vomiting & weakness for two days. He states
he has taken the medications for vomiting but can’t hold anything down. He feels dizzy when
standing up and feels very weak. Currently being treated for tongue cancer. He is on cycle 3/5 of
chemotherapy & radiation.
Past Medical History:
Hypertension
Gout
Past Surgical History:
Surgical resection-base of tongue
Current Medications:
● Lisinopril-hypertension
● Colchicine-gout
● Ondansetron-nausea
● Chemotherapy combined with radiation x7days-every other week for 5 weeks
o 5-fluorouracil (5-FU)
o Cisplatin
● Hydroxurea
● Magic mouthwash-stomatitis & mucositis
Allergies:
No allergies
Family History:
Mother-deceased-breast cancer, hypertension, Alzheimer’s disease
Father-deceased-CAD, hypertension, myocardial infarction, heart failure
Social History:
Occupation: retired auto factory worker
Tobacco Use: everyday
Illicit Drug Use: never
Alcohol Use: occasional use
Review of Systems: (what patient tells you)
Skin: pain & itching to face & neck, no changes in hair, no changes with nails
Mental Health: no current feelings of sadness, no sleep disturbances, no suicidal ideations
Neurological: + light-headedness, + dizziness, + paresthesia to feet & hands, no balance
problems
This study source was downloaded by 100000838234991 from CourseHero.com on 07-21-2022 14:08:05 GMT -05:00
https://www.coursehero.com/file/48215805/NR283-Case-Study-1-Fluid-Electrolyte-Acid-base-Balancedocx/
