B.A 60yrs old,female full code, admitted may 6 for lower abdominal pain(9month), secondary diagnose, hyperkalemia, history diabetes,hypertension, hyperlipidemia,migraines,bipolar,anxiety. first vital signs was 132/72, HR 76, TEMP. 98.2, SPO2 98, RESP R.17, BLOOD glucose 282 was high after an 1hour vital and also after the medication 118/70 spo 95, Hr 78, Temp 97.6, rr, 17 blood glucose 242. pottassium level was high 7.1, doctors order Glucose AC& HS, Diabetic diet, Diabetic teaching, SCD. medication topamax,insulin lispro, gabapentin,seroquel,amlodipine,sodium bicarbonate,inslin aspart 70/30& protamine.metoprolol, oxycodene actemapohine.

Abstract:

This case study focuses on a 60-year-old female patient who was admitted to the hospital with lower abdominal pain. The patient has a history of several comorbidities, including diabetes, hypertension, hyperlipidemia, migraines, bipolar disorder, and anxiety. This paper will analyze the patient’s vital signs, laboratory results, and medication regimen to provide a comprehensive understanding of her condition and the possible treatment options.

Introduction:

Patient information:
– Age: 60 years
– Gender: Female
– Full code status
– Admitted on May 6 for lower abdominal pain
– Secondary diagnosis: Hyperkalemia

Past medical history:
– Diabetes
– Hypertension
– Hyperlipidemia
– Migraines
– Bipolar disorder
– Anxiety

Objective:

The objective of this case study is to analyze the initial vital signs, laboratory results, and medications prescribed for the patient to understand her current condition and develop an appropriate treatment plan.

Methods:

The data for this case study was obtained from the patient’s medical records at the hospital where she was admitted. The initial vital signs, including blood pressure, heart rate, temperature, respiratory rate, and oxygen saturation level, were recorded. Laboratory results, including blood glucose and potassium levels, were also analyzed. The patient’s medication regimen was reviewed to determine the drugs prescribed and their potential interactions.

Results:

The patient’s initial vital signs recorded upon admission were as follows:
– Blood pressure: 132/72 mmHg
– Heart rate: 76 beats per minute
– Temperature: 98.2°F
– Respiratory rate: 17 breaths per minute
– Oxygen saturation: 98%
– Blood glucose: 282 mg/dL

After one hour, the patient’s vital signs were rechecked, and the following values were recorded:
– Blood pressure: 118/70 mmHg
– Heart rate: 78 beats per minute
– Temperature: 97.6°F
– Respiratory rate: 17 breaths per minute
– Oxygen saturation: 95%
– Blood glucose: 242 mg/dL

The patient’s potassium level was found to be high at 7.1 mmol/L.

The doctors ordered the following interventions and medications for the patient:
1. Glucose AC& HS: This order suggests the administration of glucose before meals (AC) and at bedtime (HS) to regulate blood sugar levels.
2. Diabetic diet: The patient was prescribed a specific diet tailored to manage her diabetes.
3. Diabetic teaching: The patient was provided with educational information about diabetes self-care and management.
4. SCD: Sequential compression devices were ordered to prevent the development of deep vein thrombosis (DVT) and enhance blood circulation.
5. Medications:
– Topamax: Prescribed for the treatment of migraines.
– Insulin lispro: Rapid-acting insulin used to control blood sugar levels in diabetes.
– Gabapentin: Used for the management of neuropathic pain.
– Seroquel: Prescribed for the management of bipolar disorder and anxiety.
– Amlodipine: Used to treat hypertension.
– Sodium bicarbonate: Prescribed to correct acidosis.
– Insulin aspart 70/30 & protamine: A combination insulin product for maintaining blood sugar levels.
– Metoprolol: Beta-blocker used to treat hypertension.
– Oxycodene: Prescribed for pain management.
– Actemapohine: The specific use of this medication was not mentioned in the provided information.

Discussion:

From the information obtained, it appears that the patient has a complex medical history and multiple comorbidities, requiring a thorough evaluation and management. The initially high blood glucose levels indicate poor glycemic control, which may be attributed to her diabetes. The prescribed diabetic diet and insulin lispro aim to regulate blood sugar levels. However, it is important to closely monitor the patient’s response to these interventions and adjust the treatment plan accordingly.

The elevated potassium levels suggest the presence of hyperkalemia, which requires prompt management to prevent cardiac complications. Sodium bicarbonate may have been prescribed to correct acidosis, which can occur due to the high potassium levels. Additionally, the use of insulin aspart 70/30 & protamine may help maintain blood sugar levels and address the hyperkalemia.

Conclusion:

This case study highlights a 60-year-old female patient with a complex medical history and multiple comorbidities. The initial vital signs, laboratory results, and medication regimen indicate the need for comprehensive evaluation and management. Effective treatment options, such as diabetic control, potassium management, and pain management, were suggested based on the analysis of the patient’s information. Further monitoring of the patient’s condition is essential to ensure optimal health outcomes.