Clinical Pickup Report...

Student:

Date Created: 2011-03-21

Ngo, David

Patient Info: 671168 X,X

Gender: F Age: 72

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Allergies
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Allergen: sufamamid antibiotics

Reaction: Other:
SeverityUnknown
Confidence Level: Very Reliable
InformantPatientAllergen:
Reaction: Other:
SeverityUnknown
Confidence Level: Very Reliable
InformantPatientAllergen:
Reaction: Itching
SeverityUnknown
Confidence Level: Very Reliable
InformantPatient

tape
latex

Health History
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Diabetes,Seizure Disorder,COPD,Pneumonia,Cirrhosis,GI Bleeding,Dementia,

Diagnosis Section
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Primary Diagnosis: GI Bleeding

Patho-Physiology:
Lower GI bleeds occur distal to the suspensory ligament of the duodenum, and may occur at any location between the duodenum
and the anus. The most common cause of lower GI bleed in the elderly is due to diverticulosis. Younger patients are more likely to
have lower GI bleeding from hemorrhoids. Other causes of lower GI bleeds include inflammatory bowel disease, mesenteric
ischemia, arteriovenous malformation (AVM) such as angiodysplasia, and infections. Diverticulosis - Diverticula form on part of the
wall of colon, usually in a weakened area of teh bowel wall.Angiodysplasia - is a malformation in the bolld vessels in the wall of the
GI tract. The sores are most common in the large intestine and often bleed. The elderly and people with chronic kidney failure
develop the disease most often.Hemorrhoids are swellings of veins in and around rectum area. Repeated stretching from straining
at stool causes to bleed. Symptoms: Acute gastrointestinal bleeding first will appear as vomiting of blood, bloody bowel movements,
or black, tarry stools. Blood may look like "coffee grounds." Symptoms associated with blood loss can include the following: fatigue
r/t loss of circulating blood volume and decreased ability to transport oxygen; weakness; shortness of breath; abdominal pain; pale
appearance; anemia; Fear r/t threat to well-being, potential death; Deficient fluid volume r/t gastrointestinal bleeding.Risk factors for
gastrointestinal bleeding include: elderly, coagulopathy, liver disease, Treatment with blood thinner medication such as coumadin,
heparin, daily aspirin use, regular or heavy use of nonsteroidal anti-inflammatory medications include Ibuprofen, naproxen,
ketoprofen, peptic ulcer disease, esophageal varices, acid reflus disease. (Kluwer, 2008, Pg. 269)Nursing Diagnosis: Risk for
bleeding r/t active fluid volume loss AEB; Bloody stool x5; potassium =5.2, Chloridem = 114; IV NS 75cc Hrs; H/H 96hrs x3;
Hemoglobin =10;

Therapeutic Regimen/Current Health Problems:

Medical therapy include vasoconstrictive agents such as vasopressin. Administration of intra-arterial vasoconstrictors may be
needed in severe, prolonged bleeding. Superselective embolization of the mesenteric vessels is an alternative technique for
treating massive lower GI bleeding. Colonoscopy - examined area such as anus, rectum and entire colon, Endoscopi coagulation.
(Pagana, 2010, Pg. 620)

Related Functional Changes:

Becareful with daily dietary, must increase fiber such as fresh fruits, wheat, bran cereal.Monitor symptoms and bleeding. Pain
Management. (Moorhouse, 2010, Pg. 314)

No Medications Found...
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Laboratory Orders
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Test:

A/G Ratio

Date Ordered: 2011-03-18

Test Description/Definition:
Total protein measurements can reflect nutritional status. Sometimes conditions are first detected with routine testing before
symptoms have begun to appear. If total protein is abnormal, further tests must be performed to identify which specific protein is
abnormally low or high so that a specific diagnosis can be made. Total protein measurements can reflect nutritional status and may
be used to screen for and help diagnose kidney disease, liver disease, and many other conditions.

Test Significance:
help diagnose kidney disease, liver disease, and many other conditions. Low total protein levels can suggest a liver disorder, a
kidney disorder, or a disorder in which protein is not digested or absorbed properly. Low levels may be seen in severe malnutrition
and with conditions that cause malabsorption, such as Celiac disease or inflammatory bowel disease (IBD).
Test

Result

Level

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A/G Ratio
.5
Low
Result Significance: severe malnutrition and with conditions that cause malabsorption,

Test:

Chem 12

Date Ordered: 2011-03-24

Test Description/Definition:
Lab medicine A battery of 12 clinically important tests on serum analytes, which are often ordered together-albumin, alk phos, AST,
calcium, cholesterol, glucose, LD, phosphate, total BR, total protein, urea nitrogen-BUN, and uric acid.

Test Significance:
electrolytes are out of balance can help your doctor to determine the cause and treatment to restore proper balance. Also it will help
the doctor to treat the blood volume deficit.
Test

Result

Level

Calcium
none
Result Significance:
Albumin
2.4
Low
Result Significance: Low levels of albumin occur in malnutrition, diarrhea, fever, infection, liver disease, inadequate
iron intake. Low levels of albumin occur in malnutrition, diarrhea, fever, infection, liver disease, inadequate iron intake.
Total Protein
none
Result Significance:
Sodium
none
Result Significance:
Potassium
5.2
High
Result Significance: anxiety, weakness, abnomal cramps, paresthesia, and diarrhea
Chloride
114
High
Result Significance: Elevated levels are related to acidosis as well as too much water crossing the cell membrane.
BUN
none
Result Significance:
Creatinine
none
Result Significance:
ALP
236
high
Result Significance: Hepatitis, Hyperparathyroidism, Leukemia, Liver disease
ALT (SGPT)
none
Result Significance:
AST (SGOT)
none
Result Significance:
Glucose
none
Result Significance:
Bilirubin, Total
none
Result Significance:
Bicarbonate
none
Result Significance:

Test:

CBC

Date Ordered: 2011-03-24

Test Description/Definition:
The CBC is used as a broad screening test to check for such disorders as anemia, infection, and many other diseases.

Test Significance:
help determine their general health status.
Test

Result

Level

Neutrophils
none
Result Significance:
Lymphocytes
none
Result Significance:
Monocytes
none
Result Significance:
Eosinophils
8.6 %
High
Result Significance: They increase in number with allergy and some parasitic conditions and decrease with steroid
administration.
Basophils
none
Result Significance:
Hemoglobin (Hgb)
10
Low

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Result Significance: Decreased with anemia

Hematocrit (Hct)
30.9
Low
Result Significance: Decreased with anemia
Platelet Count
none
Result Significance:
MCV
none
Result Significance:
MCH
none
Result Significance:
MCHC
none
Result Significance:
RDW
18.3
High
Result Significance: Increased RDW indicates mixed population of RBCs; immature RBCs tend to be larger
RBC count
3.13
low
Result Significance: Decreased with anemia
WBC count
none
Result Significance:

Test:

Phenytoin

Date Ordered: 2011-03-24

Test Description/Definition:
The phenytoin test is used to measure and monitor the amount of phenytoin in the blood and to determine whether drug
concentrations are in the therapeutic range.

Test Significance:
phenytoin tests may be ordered if a person starts or stops taking additional medications (to judge their effect, if any, on phenytoin
levels) and may be ordered if the person has a seizure or if a doctor suspects toxicity.
Test

Result

Phenytoin
6.8 mcg/ml
Result Significance: Kidney failure, Liver disease, Low blood levels of albumin

Level
Low

No Radiology Tests Found...

Page Number: 3