You are called to see Ms R, a 53 year old woman who came to the emergency

Question Answered step-by-step You are called to see Ms R, a 53 year old woman who came to the emergencydepartment (ED) because she has been feeling poorly. The nurse hands you the ED chart, which indicates current medications are Benadryl and Aspirin, she has no allergies, and initial vital signs are: temperature 37.4, respiratory rate 18, heart rate 92, blood pressure 119/77. When you arrive, Ms. R. is seated on the exam table wearing a patient gown. She appears comfortable and well developed. She states that she has been feeling poorly for about a month. Last month she was seen in clinic, diagnosed with pneumonia, and given azithromycin for a week, but felt no better. Since then she has felt worse and worse. You notice that she is alert, responds appropriately to questions, but appears quite pale, and you ask about fatigue. She confirms that she is tired all the time, and that she gets very short of breath, with a feeling of chest tightness, with any exertion. You ask the nurse to place the patient on 2 liters per minute oxygen by nasal cannula, start an IV, and order a blood count, blood chemistries, cardiogram, chest xray, and cardiac enzyme tests. On questioning, Ms. R reports she has no chest pain or trouble breathing at rest, and has had none today. Listening to her lungs, which are entirely clear to auscultation, with no rales or wheezing, you notice ankle edema, and she confirms that she has had swelling of her ankles for about three days. Now directing your attention to her eyes, you find that her pupils are equal, round, and reactive to light, her extraocular motions are intact, but her conjunctiva are quite pale. On request she opens her mouth, where you again notice the pallor of her oral mucosae, which are nevertheless moist. On questioning, she answers that she did notice some dark stools last month, but she denies any bright red blood per rectum, any hematemesis, or any coffee ground emesis, and she denies any abdominal pain or problems with her appetite or bowels. While testing her reflexes, which are normal, you ask about alcohol and tobacco: she drinks a glass of wine on holidays or special occasions, and does not smoke. In response to your questions, she denies any family history of cancer or stomach or bleeding problems, and she denies any past history of diabetes, high blood pressure, high cholesterol, or heart problems. Listening to her heart, you notice a grade III/VI systolic murmur and normal heart sounds, with no gallop. Asking her to lie down, you find that her neck is supple, her abdomen is nontender, without hepatosplenomegaly or masses. The EKG tech shows up and performs a cardiogram while you take a complete review of systems, which is negative, and then test her muscle strength, which is normal. You are handed the EKG, which shows a sinus rhythm at 82 with no changes of myocardial ischemia. You check the pulses in her feet, which are normal, and notice 1+ pitting edema. The nurse returns with preliminary lab reports: the white blood cell count is 6.1, the hematocrit is 15.6%, the platelet count is 497 thousand. Her electrolyte panel is normal. You order the nurse to type & cross match two units of packed red blood cells, and call Admitting for a bed.1. What kind(s) of information do you find here? 2. How would you describe the structure of this information? Health Science Science Nursing NURS 311 Share QuestionEmailCopy link Comments (0)