Patient Profile D.G. is a 72-year-old man who has recently experienced the loss of his wife six months ago. Concerned about his father’s deteriorating health, his daughter brings him to the healthcare provider for evaluation. D.G. has a history of hyperlipidemia and is currently prescribed niacin-lovastatin 500/20 mg orally (PO) once daily at bedtime.

 

Subjective Data

According to the patient’s report, several subjective symptoms and observations have been noted: Fatigue: D.G. has been experiencing unusual tiredness for the past few months. This persistent fatigue suggests a decline in his overall energy levels. Shortness of breath and palpitations: The patient frequently experiences shortness of breath and describes sensations of his heart pounding. These symptoms may indicate underlying cardiovascular issues that require further investigation. Weight loss: D.G. has lost weight recently, which can be attributed to his altered eating patterns since the passing of his wife. Previously, his wife took care of the cooking, and he has been unable to maintain proper nutrition by cooking himself.

NR 324 Week 4 Monday Case Study

Dietary habits: The patient describes his typical daily meals as coffee and a donut for breakfast, a hot dog and lemonade for lunch, and a jelly sandwich on white bread and coffee for supper. This dietary pattern lacks variety and may not provide the necessary nutrients for maintaining good health. Considering the subjective data provided, it is evident that D.G.’s physical and emotional well-being has been significantly affected since the loss of his wife. His fatigue, shortness of breath, and weight loss warrant further investigation to determine the underlying causes and develop an appropriate management plan that addresses his nutritional needs and emotional well-being.

Physical Examination

During the physical examination, the following objective data were observed:

  • Blood pressure: 118/72 mmHg, indicating a regular blood pressure reading.
  • Pulse: 98 beats per minute, within the normal range.
  • Temperature: 98.2°F (36.8°C), implying an average body temperature.
  • Respirations: 16 breaths per minute, within the normal range.
  • Oxygen saturation: 92% on room air, slightly lower than the optimal range.
  • Height: 5’6″ (167.6 cm), providing information about the patient’s stature.
  • Weight: 135 lb (61.2 kg), indicating the patient’s current weight.
  • BMI: 21.7 kg/m², within the normal range, suggesting a healthy body mass index.
  • S1 and S2 heart sounds were auscultated and found to be regular.
  • Bilateral radial pulses were palpated and found to be +3 and regular, indicating solid and equal vibrations on both sides.
  • Lungs were clear bilaterally upon auscultation, suggesting normal respiratory function.

NR 324 Week 4 Monday Case Study

Diagnostic Studies

The diagnostic studies yielded the following results:

  • Red Blood Cell count (RBC): 3,300,000/μL, indicating a significantly low red blood cell count.
  • Hemoglobin: 8.3 g/dL, which is lower than the normal range, suggesting the presence of anemia.
  • Hematocrit: 24%, confirming the diagnosis of anemia as it falls below the expected range.
  • Mean Corpuscular Volume (MCV): 73 fL, indicating microcytic red blood cells, a characteristic of certain types of anemia.
  • Mean Corpuscular Hemoglobin (MCH): 23 pg, further supporting the diagnosis of microcytic anemia.
  • White Blood Cell count (WBC): 9,100/μL, within the normal range, suggesting a normal immune response.
  • Platelet count: 250,000/μL, within the normal range, indicating normal blood clotting function.
  • Iron: 28 mcg/dL, potentially indicating low iron levels.
  • Ferritin: 14 ng/mL, below the expected range, may suggest iron deficiency.
  • Cobalamin (Vitamin B12): 600 pg/mL, within the normal range.
  • Folate: 10 ng/mL, within the normal range, suggesting adequate folate levels.

Based on the objective data obtained from the physical examination and diagnostic studies, the patient exhibits signs of anemia characterized by low red blood cell count, decreased hemoglobin and hematocrit levels, and microcytic red blood cells. Additionally, the patient’s oxygen saturation is slightly below the optimal range. Further investigation and interpretation of these findings are necessary to identify the underlying cause of the anemia and develop an appropriate treatment plan.

Discussion Questions

Interpreting D.G.’s laboratory results reveals several concerning findings. The low red blood cell count (RBC) indicates the presence of anemia, likely caused by bleeding. Additionally, the low hemoglobin level is consistent with anemia. The decreased hematocrit is also attributed to over-hydration. The mean corpuscular volume (MCV) value, which measures the average size of red blood cell

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