CASE STUDY I with his wife of 35 years, and has 2 grown children. He has smoked rt failure. He is compliant with his he has not been successful quitting Mr. B. is a 58-year cigarettes since the age of 23, and currently smokes 1 ppd. He drinks watching sports on TV. His past health history includes arthritis and mild chronic medications and sees his primary care physician regularly for follow up. However smoking. He has tried to quit on his own and has never attended any smoking old black man. He is married, lives beer on the weekends, usually 1 -2 cans when hea job is becoming increasingly stressful as he tries to compete with Mr. 8. has experienced increased indigestion He is employed as a car salesman and reports that his coworkers who are “younger more energetic”. Over the past 2-3 months, Mr stomach pain. He has taken OTC antacids with little relief. Two days ago he to see his primary care provider and led to his admission to the hospital for evaluation. began to pass black stools, which caused Admission Diagnoses: GI bleed Hx of Heart failure Arthritis Meds on admission: . enalapril 5 mg b.i.d . naproxen 500 mg b.i.d. Admission labs Hgb-10.3g/dL (12-18 g/du) Platelets- 162-109/L (150-450-109/L) INR-1.1 (0.8-1.2) LFTs-all WN
CASE STUDY signs: BP 110/66-T 98.3-P 92-R 20-Ht. 5’11”-wt. 254# His medications were stopped On admission an IV of wa pending further evaluation. Results o normal saline was started and an endoscopy was performed. hospital. with biopsy confirmed the diagnosis of a bleeding duodenal ulcer d from the H. pylori. Provided his condition remains stable, he is expecting to be discharge Discharge Diagnosis PUD . Anemia 2° GI bleeding ulcer . Osteoarthritis . Heart Failure Discharge Orders Omeprazole 20 mg po daily before same meal for 4 weeks . Repeat colonoscopy in 1 month . d/c naproxen INSTRUCTIONS You are the nurse during his initial visit to the hospital. After completing a comprehensive health history and physica examination, you move on to provide client education on his medicotions and three health promotion topics
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