CASE SCENARIO: Liver Cancer 1. MAKE A LABORATORY DIAGNOSIS & PROCEDURE USING THE CASE SCENARIO. CLINICAL SCENARIO NURSIN

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Case Scenario Liver Cancer 1 Make A Laboratory Diagnosis Procedure Using The Case Scenario Clinical Scenario Nursin 1 (202.29 KiB) Viewed 178 times

CASE SCENARIO: Liver Cancer 1. MAKE A LABORATORY DIAGNOSIS & PROCEDURE USING THE CASE SCENARIO. CLINICAL SCENARIO NURSING HEALTH HISTORY: PATIENT'S PROFILE Name of Patient: Patient J.B Date of Birth: February 20, 1981 Sex: Female Religion: Roman Catholic Civil Status: Single Nationality: Filipino Date Admission: November 30, 2021 Time: 08:00 AM Chief Complaint: Abdominal Tenderness Admitting Diagnosis: Liver Cirrhosis HISTORY OF PRESENT ILLNESS J.B a 40-year-old female is being evaluated for a new onset ascites and lower extremity edema. She has been hospitalized for 2 weeks for an upper GI bleed. She had an EGD for varices. J.B. was on na oxen 220 mg TID for lower back pain for two and weeks prior to her hospitalization. She was discharged on omeprazole 20 mg BID. A review of symptoms shows that she is forgetful, does not sleep well, is drowsy fatigued during the day which prevents her from working full-time. She has no complaints of abdominal pain. No complaints of chest pain and no history of coronary heart disease. She does not smoke and her family history is unremarkable. Her BP is 132/82; Pulse 88 bpm, Temp 99.0°F, weights 235 lbs. She is alert to person and place but not time, her abdomen is distended with mild tenderness upon palpation, 2" edema to mid-calf and pedal pulses barely palpable, she is positive for asterixis, and her skin had a few spider veins on her face and upper chest. BUN 8mg/dL creatinine 1.0 mg/dL; AST 68 IU/mL; ALT 46 IU/mL; albumin 2.5 g/dL; K. 3.8 mEq/dL. PAST MEDICAL HISTORY & SURGICAL HISTORY J.B. has a 10-year history of type 2 diabetes mellitus, hypertension and hypercholesterolemia. She drank alcohol moderately heavy in her 20s and currently drinks less than 3 drinks per week. FAMILY HISTORY (-) Hypertension (-) DM (-) Cancer PHYSICAL EXAMINATION Initial physical exam reveals Temperature - 99°F, Heart Rate - 88bpm, respiratory rate - 24cpm, BP - 132/82, Wt. - 235lbs., and O2 Saturation - 90% on room air. HEENT: • Head: Normocephalic And Atraumatic • Mouth: Moist Mucous Membranes • Macroglossia • Eyes: Conjunctiva and EOM are normal. Pupils are Equal, Round, and Reactive to Light. No Scleral Icterus. Bilateral periorbital edema present. • Neck: Neck Supple. No JVD Present. No masses or surgical scarring. • Throat: Patent and moist CARDIOVASCULAR: normal rate, regular rhythm, and normal heart sound with no murmur. 2+ pitting edema to mid-calf and pedal pulses barely palpable. PULMONARY/CHEST: No respiratory status distress at this time, ABDOMINAL: Distended with mild tenderness; (+) ascites SKIN: Skin had a few spider veins on her face and upper chest NEUROLOGIC: Alert, awake, able to protect her airway. Moving all extremities. No sensation losses