P.C. is a 64-year-old Muslim male who has been to the ED sev
P.C. is a 64-year-old Muslim male who has been to the ED several… P.C. is a 64-year-old Muslim male who has been to the ED several times before with the same complaint he has today3-20-2022 at 10 pm. He is complaining of a pain to his sinuses and frequent headaches. He is not seen until 3-21-2022 at 0600 as the ED was extremely busy. This is his third visit to the ED for the same complaint in the last three weeks, and the ED staff are now wondering if he is “Drug Seeking” and refer to him as a frequent flyer (This label is used to categorize patients who have been to the ED several times in the past for the same problem and who seem to feel better after pain medications are administered). His wife is with him, and he has requested male nurses only as the hospital gown are short sleeved revealing his arms and stop at the knee revealing his legs which should be covered in the presence of non-family.He overheard the nurse refers to him as a “Frequent Flyer,” and became upset. His wife calms him down but now he feels unsure about sharing how he feels. PMH: Diet controlled HTN, Hypercholesterolemia, and a Concussion at age 20 from playing soccerPSH: Hernia repair 19 years oldSocial History: Denies alcohol, smoking, or using illicit drugsMedication: Simvastatin 10 mg po q hsThe nurse admitting the patient to the ED today works part-time for an ENT medical practice and decides to a completed a focused HEENT assessment along with the Head-to-Toe. Here are the assessment findings are:Vitals: Temperature 99.6 degrees, Pulse: 90 bpm, Respirations: 22 bpm, Blood Pressure 126/78 mmHg, Pulse ox: 98% on R/AAllergies: Aspirin and Morphine both lead to the lips and tongue swelling plus a skin rash to extremities. Neuro: Alert and Oriented x4, Cranial nerves II-XII are grossly intact. Uses reading glasses to read fine print but no other visual impairment noted, but the patient eyes were sensitive to light bilaterally when pupils were checked. Still complaining of a headache, sinus pain, occasional dizziness, and poor appetite.Pain: Rates pain as an 8/10, The pain started three weeks ago as a mild throbbing headache after eating. The pain increases with glare and bright lights and decreases in dim light. Tylenol no longer controls the pain.HEENT: Head is normocephalic, eyes are normally spaced, nose are midline, but mouth is slightly asymmetrical with right side slightly lower than the left. Gum and buccal mucosa are dry and there is an abnormal smell to the left side of his mouth and tenderness to the left maxillary sinus when assessed. Ears are symmetrical placed, and no redness is noted to inner or outer ears. Hearing is intact. No drainage noted from eyes, ears, nose, or mouth. Musculoskeletal: Upper and lower extremities are 4/5 bilaterally in strength. Patient with active ROM to extremities bilaterally. No swelling or edema noted to any joint or to the lower extremities. Ambulates without assistance of any kind. He has had less energy than he normally has for the last three weeks. Cardiac: S1 and S2 without any abnormal sounds and regular rate and rhythm noted. All pulses to upper and lower extremities are 2 bilaterally.Respiratory: Lungs sounds are clear to all lung fields. Regular rate, depth and rhythm noted.GI: Abdomen soft, non-tender, non- distended, with positive bowel sounds to all four quadrants. Bowel movement x 1 yesterday. Appetite has been poor as chewing leads to a headache.GU: Voids freely and a sample sent for Urinalysis. Urine appeared yellow, clear with no sediments. Aromatic in smell. No pain with urination notes. Patient has voided 500 ml of urine in the last 6 hours.Integumentary: Skin is warm, dry, and intact with a Braden scale of 30. A 20 gauge IV has been placed to the left antecubital areas. It has been flushed and capped. Psychosocial/Mental Status: Patient appears worried with downward facial expressions stating this is his third trip to the ED for the headache and sinus pain and no one has really examined him. He just overheard a nurse labelling him as a frequent flyer. When he was in the ED before all they did was give him pain medication and send him home. He is afraid that something is happening in his body. He and his wife are visiting their son to help with newborn twins. Both his son and wife work 12 hours shifts as researchers. He does not want to be a burden and is worried being ill now. Lab work:Basic Metabolic Panel (BMP): Na:136 mEq/L, K:4 mEq /L, CL:100 mEq /L, CO2:24 mEq, BUN:14 mg/dl, Creatinine: 0.8 mg/dlComplete Blood Count (CBC): WBC: 15,000/cmm, HGB: 14 g/dl, HCT: 42%, PLT: 200,000/mcL The nurse reports the patient’s concerns, history, and assessment findings to the Health Care Provider (HCP) and stresses the odor noted when examining the patient’s mouth and left sinus pain with assessment. The HCP examines the patient and agrees with the nurse that the odor to the mouth and the tenderness to the left maxillary sinuses are concerning and orders a CT of the head. The results of the CT-Scan are pending. Recent vitals: T 100 degrees, Pulse 80 bpm, Respirations 22 bpm, Blood Pressure: 130/80, pulse ox 98% on R/A.He is started on:IV Antibiotics Clindamycin 200 mg IV q 6 hours and admit to observation floor for 24 hours. s Primary Medical Diagnosis (Chief Complaint): with pathophysiology, etiology (cause), and the expected clinical signs & symptoms related to the primary medical diagnosis. List 2 appropriate nursing diagnoses Health Science Science Nursing NURSING 456
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