Elizabeth Blair Archibald

Nursing Student; SWOCC 2018

Urgent Care: 05/02/2017

Patient #1: Female patient, 40 years old, present for left shoulder pain. She previously had a
meniscus cleaning surgery to left shoulder. Yesterday, patient was trying to lift her motorcycle that
fell over. Since then, she has had pain rated 8/10. Patient has been icing shoulder since injury,
and taking over the counter NSAIDs, but pain is still present. Patient does not have any drug
allergies, but gets overwhelming anxiety with steroids. Injury is deemed soft tissue, and a
radiograph is not ordered. Patient is to ice left shoulder at home every 20 minutes for 2 days.
Diagnosis: Soft tissue injury. RX- Norco 5/325 MG PO TID; Motrin 800 MG PO TID

Patient #2: Female patient, 63 years old, present with coughing, SOB, difficulty breathing, and
copious amounts of mucus production. Lungs auscultated with wheezing present. SPO2= 95%
and patient is febrile @ 99.9 F. Chest radiographs are normal per provider and rule out
pneumonia. Breathing treatment administered (Duoneb: Ibetropium/Albuterol). Patient had
decreased wheezing post administration. Diagnosis: Bronchitis
RX- Doxycycline 100 MG PO BID; Albuterol MDI 2 puffs TID for wheezing; Prometh-C 8 oz. 7.5
MG ML PO QHS for cough.

05/02/2017 @ 1000.
Diagnosis: Bronchitis
D: Patient present with coughing, SOB, difficulty breathing, and copious amounts of mucus
production. Lungs auscultated with wheezing present.
A: Breathing treatment administered (Duoneb: Ibetropium/Albuterol).
R: Wheezing in lungs decreased.
S: Liz, RN Student

Patient #3: Female patient, 30 years old, was in a physical altercation last night. She fell and
landed on the back of her right sided neck, and right side occipital skull around 7 PM last night.
Patient decided to come in because of persistent headache, and vision changes (blurriness).
Neuro check showed: ability to stick out tongue, puff cheeks, shrug shoulders, follow all fields of
vision, PERRLA, intact flexion and extension to upper/lower limbs and neck, and negative for
Rombergs Sign. Discussed slight possibility of subdural hematoma, but provider states that it is
unlikely. Patient is to be monitored for the next 24 hours, and to be taken to the E.D. immediately
if symptoms worsen. (nausea, vomiting, coma, etc.) Patient declines pain meds. She is to take
Ibuprofen and anti-nauseas OTC, rest, and be under observation. Patient mentioned that she has
difficulty sleeping and that Xanax has worked for her in the past. RX- Xanax 0.25 MG PO QHS
PRN #15.

Patient #4: Male patient, 50 years old, present for coughing, with green/yellow sputum, and full
body aches/pain. Lungs sound harsh to auscultation. Radiographs are negative for pneumonia.
Administered Duoneb breathing treatmentDiagnosis= Bronchitis, and reactive airway disease.
RX- Z-Pack, Albuterol MDI 2 puff PRN for wheezing, Proneth-C 8 oz. 7.5 MG ML PO QHS for
cough.

Patient #5: Female patient, 73 years old, present for concentrated/turbid urine, with burning during
voiding. Patient also has pain in mid back area. Urinalysis ordered WBC count elevated. Blood
work not performed. Diagnosis: UTI with early pyelonephritis.
RX- Septa DS PO BID; and Penicillin 100 MG PO QID.

Patient #6: Male patient 65 years old, present with HTN crisis. BP= 257/126
Stat EKG: prolonged QT, left axis deviation, and probable left atrial enlargement. Patient has 3+
pitting edema. Patient is urged to have an IVC instilled, and have blood work done. Patient
declines because he will be paying out of pocket. Patient is also urged to go to the hospital via
ambulance because of possibility of having a stroke. Patient declines and states that his wife will
drive him.

Patient #7 Female patient, 93-year-old, present with coughing/sputum production/congestion/ear

pain. Patient has a history of leukemia. WBC= 155 thousand. Patient is on chemotherapy, is
already immunocompromised, has an elevated WBC count, and has radiographic images
consistent with pneumonia. Administered a Duoneb breathing treatment. Patient is a normal client
to North Bend Medical Center: Hematology and Oncology. Patient diagnosed with Pneumonia.
RX- Azythromycin 200 MG PO QD #8, Tessalone Pearls 100 MG #20 for cough.

05/02/2017 @ 1300.
Diagnosis: Leukemia and Pneumonia.
D: Patient present with coughing, SOB, difficulty breathing, and copious amounts of mucus
production. Lungs auscultated with wheezing present. WBC= 155,000 and chest
radiographs consistent with pneumonia.
A: After administering breathing treatment, nursing student took the task of getting into
touch with Dr. Cook at North Bend Medical Center. She informed the doctor of patient
name, date of birth, pertinent lab data, and P.A. concern. Then she passed the phone over
to Howard Croy, P.A.
R: Croy and Cook corresponded about direction of care for patient. Patient will be sent on
antibiotics, and will follow up with PCP (Brom) and Hematologist/Oncologist (Cook)
S: Liz, RN Student

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Patient #8: Female patient, 11-year-old, present with diffuse rash present all over body. Rash has
a sand paper feel to it, characteristic of eczema. Rash is raise, but not very red. It is itchy per
patient. It is recommended that patient use only mild soaps, and tepid water for bathing. It is
stressed that we dont want to strip the natural oils from the patients skin. A regular over the
counter lotion is recommended. RX- Triamcinolone Cream1 % 60 grams, Prednisone 30 MG PO
QD for 5 days, Benadryl 25 MG OTC PRN for itching.