Case Study

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Written Case Study Assignment HNB2102

Mr Hay is an 82 year man who has been in your ward for the past week. On admission he was complaining of sharp pain in his chest which is worse on deep inspiration and coughing. His respirations were shallow and he tended to use purse lip breathing with use of accessory muscles. His temperature was 38 C heart rate 106 beats per minute and his respiratory rate 28 breaths per minute. His family were concerned as he was found on the kitchen floor by a neighbour, and he had been laying there for some time as he had signs consistent with a Stage 1 pressure injury to his right hip, ankle and shoulder. He also had a productive cough, with thick yellow sputum. He stated that he had been to his General Practitioner (GP) approximately a week prior to admission and was given antibiotics for the cough.

Medical History

2010: Fractured neck of femur (#NOF) and pulmonary embolism
2011 January: Partial thickness burn to left hand
No other significant medical history

Social History

Married for 45 years, wife deceased 2011
Retired from coal mining in 1990
Social drinker, likes a scotch in the evening
Lives by himself and states he copes well. Family lives a few hours away but they visit him regularly

Present Vital Signs

Pulse:
98 beats per minute
Temperature: 37.6o C
Blood Pressure 150/95 mmHg
Respirations: 28 breaths per minute at rest and shallow with ongoing complaint of pleuritic chest pain
Electrolytes

K+ - 5mmol/L
Na+- 135mmol/L
CL- 92mmol/L

Arterial Blood Gases -49 mmHg
PaCO2 PaO2 - 82 mm Hg
HCO3 - 29 mmHg
pH- 7.4

Chest X-Ray (AP and Lateral view)

Results

The lungs are hyperinflated. There are several poorly defined small pleural plaques evident bilaterally which may be consistent with long standing inflammatory change. High resolution CT scanning of the chest may be advisable to further characterize these lesions. The heart shows moderate enlargement and the lung fields are free...
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