Dorothy Markham, 78 yrs Female CC: “Diarrhea” (NUR 6104)
2 DIFFERENT VERSIONS OF THE ANSWER EXPERT
FEEDBACK(SOLUTIONS)2023 UPDATE
CONTENTS : QUESTIONS ,OLD-CARTS for the HPI,(PMH,FH,SH as Needed),PHSICAL
EXAM,EXAMS FEEDBACK,CASE FINDINGS,FEEDBACK,DIFFERENTIAL RANKING
,DIAGNOSIS,CASE PLAN, List the differential diagnoses (Must not
Miss/Leading/Alternate/Concluding)
, VERSION A
Dorothy Markham
Patient is 78 yo female who currently resides in a nursing home. Recently treated with antibiotics
for UTI. History of GERD, HTN, osteoporosis, she is a former smoker: 20 pack-year history
who admits to have 1 drink per week. Ms. Markham presents to ED with acute, non-bloody,
diarrhea, bloating, nausea and diffuse abdominal pain of 2 days in duration. She had multiple
bowel movements on the first day and she reports cramps, which come and go, pain level 6/10
and rest makes it better. She denies blood in stool, or fecal incontinence has little appetite caused
by nausea. She denies sick outbreak at rehab facility or recent travels. She has not been able to
associate her symptoms with dietary triggers. Not sure about fevers but states that she felt warm
for last couple days, complains of dizziness and being lightheaded. She has clinical signs of
orthostatic hypotension with volume depletion due to her inability to maintain adequate oral
hydration and her ongoing use of diuretics. Skin tenting is present on the back of the hand,
capillary refill is greater than 2 seconds. Patient MMSE 28/30. WBC 18,000 without left shift,
elevated lactate 2.5 mmol/L, elevated BUN and creatinine ratio > 20:1, concentrated urine and
positive clostridial toxin assay indicating C. diff organism. Both parents deceased, father died of
heart attack at 60 yo, children are ok, HTN runs in her family and both her and her brother.
Assessment/Plan:
Primary Diagnosis: C. difficile colitis. Acute renal failure from dehydration/hypovolemia
secondary to acute diarrhea
Status/Condition: Stable
Code Status: Full
Allergies: NKDA
Admit to Unit: Medical-surgical
Precaution: Contact isolation
Activity Level: Bedrest with commode, call for assistance
Diet: CC2, No Gastric irritants
IVF: NS@100 notify NP if patient able to tolerate diet and has no nausea
Critical Drips: NONE
Respiratory: NONE
Medications:
Hold home medication
Vancomycin 125 mg PO q 6 h
PRN:
Zofran 4 mg IV q 6 h for nausea
Ketorolac 15 mg IV Soln q 4 pain (4-6)
Ketorolac30 mg IV Soln q 4 pain (7-10)
Nursing Orders:
Orthostatic Vital signs Q shift
Skin care, toileting, ambulation etc.
Encourage oral hydration as tolerated, monitor I&O
DVT/PE prophylaxis- Teds
Follow Up Lab tests: CBC, Lactic acid,
2 DIFFERENT VERSIONS OF THE ANSWER EXPERT
FEEDBACK(SOLUTIONS)2023 UPDATE
CONTENTS : QUESTIONS ,OLD-CARTS for the HPI,(PMH,FH,SH as Needed),PHSICAL
EXAM,EXAMS FEEDBACK,CASE FINDINGS,FEEDBACK,DIFFERENTIAL RANKING
,DIAGNOSIS,CASE PLAN, List the differential diagnoses (Must not
Miss/Leading/Alternate/Concluding)
, VERSION A
Dorothy Markham
Patient is 78 yo female who currently resides in a nursing home. Recently treated with antibiotics
for UTI. History of GERD, HTN, osteoporosis, she is a former smoker: 20 pack-year history
who admits to have 1 drink per week. Ms. Markham presents to ED with acute, non-bloody,
diarrhea, bloating, nausea and diffuse abdominal pain of 2 days in duration. She had multiple
bowel movements on the first day and she reports cramps, which come and go, pain level 6/10
and rest makes it better. She denies blood in stool, or fecal incontinence has little appetite caused
by nausea. She denies sick outbreak at rehab facility or recent travels. She has not been able to
associate her symptoms with dietary triggers. Not sure about fevers but states that she felt warm
for last couple days, complains of dizziness and being lightheaded. She has clinical signs of
orthostatic hypotension with volume depletion due to her inability to maintain adequate oral
hydration and her ongoing use of diuretics. Skin tenting is present on the back of the hand,
capillary refill is greater than 2 seconds. Patient MMSE 28/30. WBC 18,000 without left shift,
elevated lactate 2.5 mmol/L, elevated BUN and creatinine ratio > 20:1, concentrated urine and
positive clostridial toxin assay indicating C. diff organism. Both parents deceased, father died of
heart attack at 60 yo, children are ok, HTN runs in her family and both her and her brother.
Assessment/Plan:
Primary Diagnosis: C. difficile colitis. Acute renal failure from dehydration/hypovolemia
secondary to acute diarrhea
Status/Condition: Stable
Code Status: Full
Allergies: NKDA
Admit to Unit: Medical-surgical
Precaution: Contact isolation
Activity Level: Bedrest with commode, call for assistance
Diet: CC2, No Gastric irritants
IVF: NS@100 notify NP if patient able to tolerate diet and has no nausea
Critical Drips: NONE
Respiratory: NONE
Medications:
Hold home medication
Vancomycin 125 mg PO q 6 h
PRN:
Zofran 4 mg IV q 6 h for nausea
Ketorolac 15 mg IV Soln q 4 pain (4-6)
Ketorolac30 mg IV Soln q 4 pain (7-10)
Nursing Orders:
Orthostatic Vital signs Q shift
Skin care, toileting, ambulation etc.
Encourage oral hydration as tolerated, monitor I&O
DVT/PE prophylaxis- Teds
Follow Up Lab tests: CBC, Lactic acid,
