NURS 6560 Week five IHUMAN : Fever and confusion case study

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CC: Fever and confusion HPI: The patient is an 82 year old female with past pertinent medical record of a recent CVA with residual right-sided deficits, dysphasia, and HTN, who presents to the emerg... ency department with new onset confusion and a fever. The patient was previously hospitalized for five days following a CVA, which left the patient with right-sided deficits, and dysphasia. Speech therapy currently has her on a soft food diet, as she will cough with eating if she does not eat slowly. She has been at a rehab facility for ten days following the recent hospitalization, and she has actively been working with physical therapy until yesterday. She refused her physical therapy yesterday, had a poor appetite, developed a cough, dyspnea, and she began to have a low-grade temperature of 99.6 degrees fahrenheit. As of this am, the patient was able to discuss details with her morning nurse; however, by 3:00pm she was confused, mumbling, and unable to answer questions. The patient was found to have a temperature of 101 degrees fahrenheit, and she was tachycardic at 120 bpm. The patient was transported to the hospital due to these changes. Onset: Location: Duration: Characteristics: Associated signs and symptoms: Timing: Exacerbating/ relieving factors: Current Medications: Allergies: NKDA PMHx: CVA with right sided deficits, HTN, and dysphagia. Current on Pneumovax, influenza, shingles, and influenza vaccines. Soc Hx: Never smoked or used smokeless tobacco. Does not drink alcohol. Fam Hx: Widowed with three healthy adult children. Daughter is the POA. Father lived to the age of 96, and then died in his sleep. Mother died of a CVA complications at 86 years old. No siblings [Show More]

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