NUR 6104 Ihuman Case Study
Dorothy Markham, 78 yrs. Female CC:
“Diarrhea” 2 DIFFERENT VERSIONS
OF THE ANSWER EXPERT
FEEDBACK(SOLUTIONS)2023
... [Show More] UPDATE
CONTENTS: QUESTIONS, OLD-CARTS for the HPI, (PMH, FH, SH as
Needed), PHSICAL
EXAM, EXAMS FEEDBACK, CASE FINDINGS, FEEDBACK, DIFFERENTIAL
RANKING,
DIAGNOSIS, CASE PLAN, List the differential diagnoses (Must not
Miss/Leading/Alternate/Concluding)
VERSION A
Dorothy Markham
Patient is 78 you female who currently resides in a nursing home. Recently treated with
antibiotics for UTI. History of GERD, HTN, osteoporosis, she is a former smoker: 20 pack-year
history who admits to have 1 drink per week. Ms. Markham presents to ED with acute, non-
bloody, diarrhea, bloating, nausea and diffuse abdominal pain of 2 days in duration. She had
multiple bowel movements on the first day and she reports cramps, which come and go, pain
level 6/10 and rest makes it better. She denies blood in stool, or fecal incontinence has little
appetite caused by nausea. She denies sick outbreak at rehab facility or recent travels. She has not
been able to associate her symptoms with dietary triggers. Not sure about fevers but states that
she felt warm for last couple days, complains of dizziness and being lightheaded. She has clinical
signs of orthostatic hypotension with volume depletion due to her inability to maintain adequate
oral hydration and her ongoing use of diuretics. Skin tenting is present on the back of the hand,
capillary refill is greater than 2 seconds. Patient MMSE 28/30. WBC 18,000 without left shift,
elevated lactate 2.5 mmol/L, elevated BUN and creatinine ratio > 20:1, concentrated urine and
positive clostridial toxin assay indicating C. diff organism. Both parents deceased, father died of
heart attack at 60 you, children are ok, HTN runs in her family and both her and her brother.
Assessment/Plan:
Primary Diagnosis: C. difficile colitis. Acute renal failure from dehydration/hypovolemia
secondary to acute diarrhea
Status/Condition: Stable
Code Status: Full
Allergies: NKDA
Admit to Unit: Medical-surgical
Precaution: Contact isolation
Activity Level: Bedrest with commode, call for assistance
Diet: CC2, No Gastric irritants
IVF: NS@100 notify NP if patient able to tolerate diet and has no
nausea Critical Drips: NONE Respiratory: NONE Medications:
Hold home medication
Vancomycin 125 mg PO q 6 h
PRN:
Zofran 4 mg IV q 6 h for nausea
Ketorolac 15 mg IV Solna q 4 pain (4-6)
Ketorolac30 mg IV Solna q 4 pain (7-10)
Nursing Orders:
Orthostatic Vital signs Q shift Skin
care, toileting, ambulation etc.
Encourage oral hydration as tolerated, monitor I&O
DVT/PE prophylaxis- Teds
Follow Up Lab tests: CBC, Lactic acid,
Diagnostic testing: CT-Scan of abdomen and pelvis with contrast- if clinically safe.
Consults:
ID- C. defile management and care in and outpatient
Patient Education and Health Promotion:
*If you are given medicine to treat C. diff, take it as directed.
*Wash your hands with soap and water often.
*Wash after you go to the bathroom and before you touch food.
*People who live with you should also wash their hands with soap and water often.
* Remind visitors to wash their hands with soap and water as they come and go.
*Wash your hands often.
*Wash after you use the bathroom and before you touch food.
* Do not actively seek antibiotics for common, often viral infections (head cold).
* Only take antibiotics as prescribed by your doctor.
*Stay in your room except when you need to go for a test or procedure.
*Before leaving your room, put on a clean robe.
*No alcohol-based sanitizers.
Discharge planning and required follow-up care
*Schedule appointment with primary MD for follow-up within 7-10 days after DC if diagnosis is
unclear or symptoms do not abate with conservative treatment
*DC to rehab facility after resolution of diarrhea.
C. difficile- patients with suspected or proven CDI should be placed on contact precautions, it is
proven that washing hands with water and soap is more efficient than using hand sanitizer.
Supportive care with administration of fluids is vital. Treatments are recommended for patients
who are having typical symptoms such as >3 loose BMs in 24h without any obvious explanation.
Adjunctive diagnostic tools for evaluating patients withs CDI include radiographic imaging and
endoscopy. C. difficile is the most common infectious cause of health care-associated diarrhea
and a significant cause of morbidity and mortality among. Hospitalized patients.
References
Kelly, C. P., Lamont, T., & Bakken, J. S. (2021). Chloridoids (formerly Clostridium) difficile
infection in adults: Treatment and prevention. Retrieved from
https://www.uptodate.com/contents/clostridioides-formerly-clostridium-difficile-
infection-in-adults-treatment-and-prevention
Lamont, T., Kelly, C. P., & Bakken, J. S. (2021). Chloridoids (formerly Clostridium) difficile
infection in adults: Clinical manifestations and diagnosis. Retrieved from
https://www.uptodate.com/contents/clostridioides-formerly-clostridium-difficile-
infection-in-adults-clinical-manifestations-and-diagnosis
UW Health. (2020). What You Need to Know about Clostridium difficile (Codify) Infection
(CDI). Retrieved from https://www.uwhealth.org/healthfacts/infectious-disease
UW Health. (2020). What You Need to Know about Clostridium difficile (Codify) Infection
(CDI). Retrieved from https://www.uwhealth.org/healthfacts/infectious-di
VERSION B
Dorothy Markham
78 y/o
5’3
125 lbs.
Vitals
T: 100.76F PO
P: 90
BP: 126/72
RR; 16
O2: 97% RA
CC: Diarrhea
1. How can I help u today? – having a lot of watery diarrhea and stomach has been to
upset. Caretaker at rehab sent her here to see what’s wrong. The sent my chart over for
you to review
2. Any other symptoms or concerns we should discuss? – yes appetite is way off and
having tummy pain. Feel woozy, lightheaded when standing. Feel worn out
3. When did urn diarrhea start – 2 days ago
4. What are the events surrounding the start of urn diarrhea – don’t know
5. How often do u have diarrhea like this - never
6. What Tx have u had for urn diarrhea – none
7. Is there any blood in urn stool or with BM – no
8. Do u have black tar-like or foul-smelling stool – no
9. How often do u feel that u need to move urn bowels – normally 2x/day. But when diarrhea
started it happened 2x first night, 5x yesterday, and already 2x this AM
10. When did urn Abd pain start - when diarrhea did
11. Does anything make the Abd pain better or worse – taking it easy and resting makes
better. A little better once get off toilet
12. What does the pain/discomfort in your Abd feel like? – crampy 13. Where more precisely
is your Abd pain – all over belly
14. Do u have any Abd bloating? – yes.
15. How severe (1-10) is your Abd pain – 6 at its worse
16. How long does the pain in your abdomen last? – comes just before diarrhea, then feels
better after an episode, so not too long
17. Do you have any N/V? – some nausea
18. Have u been in contact w another sick ppl – no
19. Have u been having fevers – don’t know but feel warm
20. Are u taking OTC/herbal meds – baby ASA and calcium with vitamin D
21. Any new or recent change in urn meds – ax 1 week ago
22. When did u last take urn meds? – this AM
23. Do u have any allergies, meds, foods, latex - no
24. ROS: do u have any of the following fatigue, difficulty sleeping – yes tired
25. ROS: headaches that don’t go away with ASA or Tylenol – no
26. ROS: chest pain or pressure – no
27. ROS: SOB, wheezing, diff breathing – no
28. ROS: when u urinate, have u noticed pain, boring, blood etc. – had some of that when I
had infection a week ago. Has gone away now
29. ROS: problems w muscle or joint pain – no
30. ROS: dizziness, fainting, spinning room etc. – feels lightheaded
Physical Exam:
- Skin: tenting present on back of hand. No rash, pallor, or icterus
- Cap refill nails: abnormal. Blanch times are > 2 sec
- Mouth/pharynx: dry mucous membranes & dry furrowed lounge
- Abdomen: pain upon palpation. Mild diffuse tenderness
- Neuro MMSE: not orientated to date or time
- Orthostatic BP: 106/60 “I feel funny can I please sit” [Show Less]