Patient Information

Patient name ………. Belachew abebaw

Age……………………60 yrs

Sex ……………………male

Address ……………….

Site of visit………….Emergency OPD

Date------------------26/12/2015E.C

Presenting problems:

After arriving at, Emergency OPD, at 6:00 AM, Ato Belachew complains nausea
and vomiting for 3 days duration

Discussion question 1

1. List ato Belachew’s problems

2. Define your hypothesizes
3. Which systems might be involved and describe the mechanisms leading to
the problems
4. What aspects of history would you want to ask that help you to test your
hypothesizes?

History of present illness

After arriving at Hospital, Emergency OPD at 6:00 AM local time, ato BelAchew
said that “ I have been Developing persistent nausea and vomiting since the last
three days.’’

He has also headache, intermittent seizure and loss of appetite.

There was no any management given before he comes to hospital.

Past medical history_ previously, he was treated for UTI two months ago.

Family history- He has no family history of DM, HTN or similar problems.

Personal and social history-he has good interaction with with his families and
neighbours.

ROS:

GIT- No other pertinent data

GUT- small amount of urine

Discussion question 2

1. Summarize the new information you obtained. How does these new
information contribute to your hypothesis or suggest new hypothesis?
2. What pertinent data would you expect on physical examination? How does
it help you to rerank your hypothesis?

Physical examination:

General appearance – Acute sick looking

Vital sign: BP 150/100mmHg, PR 96 bpm, RR 32 bpm, Temp 35.7

HEENT- pink conjunctiva but there is some degree of facial edema

LGS – No any enlarged lymph node.

-No lesion and no palpable mass

RS – Chest is clear and resonant

CVS- s1 and s2 well heard

-No murmur no gallop

Abdomen – No abdominal tenderness and no palpable mass. He has

nausea,vomiting and loss of appetite for days.

MSS: There is some degree of extremity edema.

IGS – There is slow capillary refill time.

GUT – There is CVA tenderness, dysuria and decreased urine output

(approximately 300ml/24hrs).

CNS – Lethargic, seizure

Discussion question 3

1. How does the physical examination help you?

2. Do you want to change the ranking order of the hypothesis based on the
physical examination? How?
3. What investigations would you request to test your hypotheses?

Laboratory Investigations and results:

  RFT: Creatinine: 1.4 mg/dl Normal value:0.6_1.02mg/dl
BUN: 27 mg/dl Normal value: 10_20 mg/dl
 WBC:10,500/mm3 Normal value:5,000_10,000/mm3
 Hgb: 12mg/dl Normal value:10_14m g/dl
 Urine analysis: many RBC/HPF, +4 protein
Discussion question 4

1. Interpret test results and re-evaluate your hypotheses.

2. Based on your hypotheses, what medical and nursing interventions do you consider for
Belachew?
3. How would you counsel his family?