Case Scenarios for Cohort 119
1) Sharon
Sharon Phillips is 48 years old. She is married to James, and they have two children; Jack is 18 and Amelia is 15 years old.
Sharon is known to have asthma, and is normally reasonably well controlled on Salbutamol inhalers. Over the last 5 days, she has developed symptoms of a respiratory tract infection. Following an episode of acute shortness of breath, which she developed whilst her husband was redecorating their bedroom, Sharon arrives at the Emergency Department (ED). She has previously been admitted to ITU 6 years ago, when she had a severe exacerbation of her asthma.
On presentation, Sharon’s respiratory rate is 26 breaths per minute, and her oxygen saturations are 90% on room air. She has an audible wheeze. She is responding to voice, but she is unable to complete a full sentence in one breath. Her heart rate is 115 beats per minute and her blood pressure is 140/85mmHg. She has a pain score of 4 out of 10, and has passed 50mls of urine in the last hour. Her blood glucose is 4.8mmols/l and her peak flow is 240. Her temperature is 38.7. She weighs 75kg.
2) Raj
Raj Patel is 68 years old. He is married to Kulvinder and they have 4 grown up children. Their eldest son Jagdeep lives in London, and their youngest daughter Kuldip still lives at home. Satpal and Kiranjit have their own families but live locally.[unique_solution]
Raj returned from theatre 6 hours ago, after a bowel resection. The surgery was uneventful, and his observations were stable in recovery.
On return to the surgical ward, Raj appears drowsy but is able to answer questions in full sentences. His blood pressure is 86/56mmHg and his heart rate is 120 beats per minute. His temperature is 36.2. His respiratory rate is 24 breaths per minute and his saturations are 90% on room air. He weighs 80kg and his blood glucose is 5.6mmols/l. Raj has passed 30mls of urine in the last hour and there is 280mls in his wound drain. He has a pain score of 8 out of 10.
3) Alice
Alice Brown is 72 years old and lives alone in a bungalow since her husband passed away 2 years ago. Both her daughters have their own homes and families, but Caroline tries to visit her mom at least a couple of times a week.
Alice is visited on alternate days by the Community nursing service to have her venous leg ulcer dressed. On her last visit, it was noted that Alice had been incontinent of urine, and her urine had an offensive odour. The community nurse was also concerned that Alice appeared to be newly confused. Following discussion with her GP, Alice was admitted to Acute Medical Unit (AMU).
On the ward, the wound dressing is removed, and it is noted that there is urine and wound exudate on the bandaging. The wound is red and inflamed. Alice’s heart rate is 112 and her blood pressure is 98/62mmHg. Her respiratory rate is 24 breaths per minute with saturations of 92% on room air. She is responding to voice. She weighs 70kg and her temperature is 39.6. Her BM is 6.2mmols, and she has passed 20mls of urine in the last hour. Alice has a pain score of 6 out of 10.
4) Nadia
Nadia Frimpong is 24 years old. Her partner Eric left her 2 weeks after she gave birth to their second child. Jack is now 3 years old and Jemima is 8 weeks old.
Nadia was well during both her pregnancies and had natural births with no complications. However while she was pregnant with Jemima, Eric’s behaviour changed, to the point that he was known to be aggressive and he had hit Nadia. Nadia’s parents have not seen her since Jack was born, because they did not approve of Eric. Since he has left, the children and Nadia have become more settled but Nadia is tired and has experienced episodes of crying for no apparent reason. She has explained to the Health Visitor that she has no maternal feelings for Jemima, but she does not want to lose her children. She currently has no energy, and no interest in looking after herself, and so the Health Visitor has made a referral for a Community Psychiatric Nurse (CPN) to visit her.
At this visit, Nadia’s respiratory rate is 24 breaths per minute. Her oxygen saturations are not measured, but she looks well perfused despite shallow breathing. She is responding appropriately, but clearly anxious. Her heart rate is 115 beats per minute and her blood pressure is 120/65mmHg. She describes pain on passing urine (6/10) and reports having to go to the toilet frequently for the last couple of days. Her blood glucose is 5.2mmols/l and her weight is 60kg. Her temperature is 38.6.
5) Jake
Jake is a 19-year-old first year psychology student, he was admitted to A&E via paramedic team. On admission, he complained of intense chest pain and difficulty in breathing. He tells the admitting triage nurse, ‘I was walking to University and I started sweating and then felt breathless. My heart was pounding so hard I thought it would explore and my legs felt weak’.
Someone noticed he did not look well and called the ambulance. On admission, Jake has an ECG recording, which is found to be in normal range. His vital signs are as follows: oxygen saturation of 98%, He has a strong pulse of 125, a shallow respiration of 30 breathes / minute, raised blood pressure 137/95 (mm Hg) and his temperature is 37.2.
Two hours after admission his heart rate is recorded at 95, his respirations down to 22 and his blood pressure is 128/89mm Hg. He weighs 72kg, and his BM is 6.2mmols/l. He tells the nurse he has not been sleeping well at night and has been worrying about imminent university exams.
Jake is currently living away from home and says he feels isolated and is a bit of a loner. He smokes 15 cigarettes a day and is a frequent coffee drinker.
6) Rosie
It is 6 pm and Rosie, a 2 year old girl has presented to the emergency department (ED) with a 24 hour history of diarrhoea and vomiting. Her parents report that she is refusing fluids and food and has had one wet nappy over the duration of the day. They also report that she has felt feverish today and has been miserable. She has been lay on the sofa, very quiet and not her usual playful self.
On arrival to the ED, Rosie is alert, but quiet. She has a pulse rate of 150 beats per minute with a respiratory rate of 40. Her temperature is 38.3 degrees. Her blood pressure is 90/60 and saturation levels are 96% in air. Her capillary refill time is 3 seconds. Her nappy that she has on now is dry and Mum reports this is the same nappy since this morning. She has no rashes. Her blood glucose level is 3.6mmol/l.
7) Michael
Michael Henderson is 6 years old and lives with his mother, Anne. He has been admitted to hospital following a 48 hour history of an upper respiratory tract infection, which has resulted in increasing breathlessness and an audible wheeze. Michael has been taking his Salbutamol inhaler at home but his mother reports that it doesn’t seem to be helping despite having it hourly for the past 4 hours.
On admission to the Children’s ward, Michael has a heart rate of 130 beats per minute and a blood pressure of 100/60 mmHg. His saturations are 88% on air, he has a tracheal tug with subcostal and intercostal rescession. Michael’s respiratory rate is 42 breaths per minute, and his blood glucose is 6.2mmols/l. He is tired but restless. He looks pale but his temperature is 38.8. Anne has asked whether her smoking in the house may have contributed to this.