Anemia Case Study Practice PDF
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Uploaded by DefeatedSagacity
Harding University
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Summary
This document presents a case study of a patient with anemia. The case details patient history, medications, labs, and assessment findings. The study includes vital signs, lab results, and symptom descriptions.
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# Clinical Judgement Measurement Model: Anemia Case Study Practice **Case:** A 78-year-old male came to ED with chest pain, shortness of breath and low blood pressure. He states "I am weak and tired all the time," and "I can't catch my breath." **History:** - Coronary artery disease - Myocardial...
# Clinical Judgement Measurement Model: Anemia Case Study Practice **Case:** A 78-year-old male came to ED with chest pain, shortness of breath and low blood pressure. He states "I am weak and tired all the time," and "I can't catch my breath." **History:** - Coronary artery disease - Myocardial infarction - Hypertension - CABG x 5 - Stents x 3 - High cholesterol - Chronic diarrhea **Allergies:** - PCN - Statins **Home medication:** - Imdur (isosorbide mononitrate) 30 mg once a day - Lisinopril 10 mg daily - Baby aspirin 81 mg daily - Plavix (clopidogrel bisulfate) 75 mg daily - Fish oil daily - Potassium 20 meq daily **EKG:** No changes, normal bradycardia at 56 **Given in ED:** - Nitroglycerin x 2 - Morphine 5 mg IV push **LABS:** | Lab | Value | |---|---| | WBC | 4000 | | RBC | 3000 | | I-IGB | 6.8 | | HCT | 19 | | Plat | 150,000 | | PTT | 25 secs | | PT | 12 | **BMP:** | Lab | Value | |---|---| | Sodium | 140 | | Potassium | 4.0 | | BUN | 15 | | Creatinine | 0.8 | | Calcium | 8.5 | | Chloride | 101 | | Glucose | 115 | **Assessment:** - Lungs clear bilaterally all fields - Heart rate SR to tachycardia 90-110 and higher with exertion - RR 28 at rest 36 with exertion - Patient reports HR usually 50-70's - BP 96/56 - Pain in abdomen and back with squeezing around chest - Alert and oriented x 4 - Hard of hearing - Speech normal - Skin pale and dry - Moves all extremities - Hand grips 4/5 and leg strength 3/5 - No complaints of problems voiding - Frequent episodes of diarrhea but none today - MD palpates a rectal mass and orders for patient to be admitted **Orders:** - Type, Cross and Transfuse 3 units of blood - Pre-medicate with acetaminophen 325 mg 2 tablets orally and Benadryl 25 mg orally - Lasix 20 mg IV push after first unit - Admit to medical-surgical unit - CT of abdomen and pelvis in am - Guaic all stools - Repeat CBC in am with Differential - Oxygen 2 liters nasal cannula
