HNB2003-Clinical Reasoning Cycle & Andrew Case Study – Medical Science Assignment Help

Assignment Task


Assessment : Additional Information for Clinical Reasoning Cycle 

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Case Study
Andrew is a 58-year-old male who is currently homeless. He was living in a supported living accommodation but recently was asked to leave due to his drinking issues. He has not worked for 2 years and started drinking heavily when his wife left him 3 years ago. He admits that when he has money, he will drink a cask of wine a night. He has been relying on the soup kitchen that comes around at nights but sometimes they run out of food and if he has no money then he often goes hungry. A few months ago he went to St Vincent’s with chest pain and they diagnosed him with Gastric reflux and put him on some sort of “acid” tablet (Gastro-oesophageal Reflux Disease and prescribed Esomeprazole 40mg mane). 

After the script ran out Andrew has not had the money to go and get it filled again. Andrew was brought to ED when a passer-by called an ambulance after he was found vomiting blood in the Bourke Street Mall and had a decreased level of consciousness. Andrew was complaining of severe epigastric pain, vomiting with blood and severe nausea. Andrew is also a smoker and is quite malnourished. 

On examination upon admission:
58-year-old male – intoxicated with strong odour of urine and alcohol
Dirty clothes and looks quite emaciated.
BP 148/96 mmHg
HR 112 beats/min
RR 22 breaths/min
Temp 36.2
SpO2 95%
Pain score 10/10
Abdominal assessment – tender in the epigastrium with mild rebound tenderness but no guarding Lab tests on admission: (reference ranges indicated below in brackets)

Hb 148 (130-180 g/L)
WCC, 16,000 (5000-10000)
PMN 75% (60-70%)
Serum Amylase 750 (60-180 units)
Glucose (Random) 7.2 (3.0 – 6.9 mmol/L)
Serum ALP 250 (30- 110 U/L)
Serum Sodium 145 (135-145 mmol/L)
Serum Potassium 4.0 (3.5- 5.2 mmol/L)
Serum Creatinine 62 (60-110 µmol/L
Serum Calcium 2.15 (2.10 – 2.60 mmol/L)

Current diagnosis: Acute pancreatitis 

Medical Orders:
Commence IV fluids Sodium Chloride 0.9% at 150ml/hr
Insert Nasogastric tube connected to low intermittent suction
Morphine 2mg IV bolus PRN for pain
Ondansetron 4mg IV bolus every 4 hours PRN for nausea
Ultrasound Abdomen

Written Assessment
Read the case study provided for Assessment 2 Written Assessment and review the rubric to identify the important aspects that you need to include in your assessment. Use the below structure for your written assessment.

TITLE PAGE: Your written assessment must have a title page that specifies – unit code & unit name, student name, student Identification number, title of assignment, an accurate word count including in-text citations but not the end references.

The body of your paper must be organised under the following headings from the clinical reasoning cycle. No separate introduction or conclusion is required for this assessment task. Refer to the attachment in the unit’s VUC titled ‘CRC Explanatory notes’ to understand what is to be included under each of these headings. Delete ALL highlighted text below prior to submission. Only your responses should be under each heading

Describe or list facts, context, objects or people

Review current information (eg patient Hx
Gather new information (eg patient Ax)
Recall knowledge (eg physiology, pathophysiology and medications): References needed here
Specific cultural consideration

Interpret the information. Ask yourself WHY…why am I seeing these signs and symptoms? Why are these blood results and vital signs abnormal? Why are these medical orders requested? Reference here to support your work.

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