Fluids and Electrolyte, Acid base situation analysis Coursework
Please use the text book Understanding pathophysiology 6th edition by Huether and McCance as one of your references. The instructions have been uploaded.
Extra Credit Mr. D.M. a 19 year old college student presents to the emergency room with the following symptoms. Subjective Data: client states he has had abdominal pain for two days. Has vomited several times and is unable to keep even liquids down. Denies using any drugs legal or illegal. States he goes to the bathroom 8 to 10 times daily, which is unusual for him. Says he can’t think clearly and is anxious because all his papers are due in the next week. States has been in good health prior to entering college. States “I want to sleep all the time and can’t go out with my friends”. States has had all immunizations and vaccinations up to date but can’t remember when he had them. Denies alcohol and tobacco use. Objective Data: Skin is flushed; lips and mucous membranes are dry and cracked. Skin turgor poor. Capillary refill less than 3 seconds. Respirations are rapid and deep. Confused and keeps repeating the same history. Crying and anxious. Asking for water. BP 90/60, Pulse 120, RR 32/min, temp 101.8 , Na 148, K 6.0, BUN 48, creatinine 3.8 Glucose 685mg/dl Ph 7.21, PcO2 55, Po2 72 HCO3 14 Here is your task. You must analyze the above symptoms using pathophysiological terminology. You must develop an Assessment and Plan for this client. This can be no more than three pages which must be concise and provides evidence of research. You must qualify your responses utilizing professional references, one of which can be your textbook. APA format is required. Rubric for Extra Credit Synthesis of Subjective data 10 points Synthesis of Objective data 10 points Plan for the Client: 7 points References (APA format) 3 points
Assessment and Plan for Mr. D.M.
Name
Institution
Due Date
Assessment and Plan for Mr. D.M.
Chief Complaint: abdominal pain, vomiting
History of Present Illness
Mr. D.M., a 19-year-old college student, presents to the emergency room after two days of abdominal pain, vomiting, nausea, and diarrhea. The student has Crohn’s Disease and stated a severe abdominal pain radiating to all four quadrants of the stomach.
Physical Examination
BP 90/60, Pulse 120, RR 32/min, temp 101.8 , Na 148, K 6.0, BUN 48, creatinine 3.8 Glucose 685mg/dl Ph 7.21, PcO2 55, Po2 72 HCO3 14
Review of Systems
Constitutional: Patient declares no signs of anorexia and weight loss
HEENT: patient says no signs of decreased hearing ability, no signs of irritation, no vision loss or eye pain, no ear pain or discharge, no signs of nasal obstruction or discharge, nose-bleeding, lack of hoarseness, or sore throat.
Cardiovascular: no signs of chest pain, palpitations, orthopnea, edema
Respiratory: patient denies signs of coughing or wheezing
Gastrointestinal: patient denies signs of jaundice
Genitourinary: patient denies signs of inconsistency in urinating, hematuria
Musculoskeletal: pain in the lower back pain from an existing past injury, no joint pains or swelling, no muscle cramps or stiffness
Skin: patient denies signs of rashes
Neurologic: denies signs of paralysis, seizures, vertigo
Psychiatric: depression, has anxiety, mentally disturbed, memory loss, hallucinations, paranoia
Endocrine: no signs of cold intolerance, heat intolerance, polyphagia
Lymphatic: no bleeding, no enlargement of lymph nodes
Allergic/Immunologic: no persistent infections, no exposure to HIV, hay fever
General Assessment
Obese and sleepy
Eyes: the lids are normal, and the pupils appear equal, round, and reactive to light. The discs are sharp and flat and have normal visual acuity
ENNT: External ears appear to be normal, external nose normal, and the canals tend to clear bilaterally with tympanic membranes being in good mobility and intact. The hearing ability is intact, however, there is poor dental formula with few missing teeth, the tongue appears normal. The neck is very supple with no thyroid nodules, tenderness, or any form of enlargement.
Respiratory
The system is clear bilaterally, there is normal tactile fremitus, and absence of egophony, there is normal respiratory flow not using the accessory muscles.
Cardiovascular
There is normal rhythm, absence of murmur, rub, or gallop; no signs of thrill or palpable murmurs upon palpation, lack of JVD, no signs of displacement of PMI; there are no signs of carotid or abdominal bruits; no presence of abdominal aorta enlargement.
Gastrointestinal
There...
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