Med Surg Paper
BT is a 95 year old Caucasian female that lives with her husband and has spent 39 years working as a missionary. She presented to the emergency room at Milford Memorial Hospital on March 17, 2012 complaining of diarrhea for the past 6 days, up to 5 times a day. She also reported loss of appetite and weakness; upon admission to the emergency room she vomited once and verbalized cramping in the upper abdominal region. She was admitted with acute infectious colitis, acute renal failure, and dehydration. Past surgeries include an appendectomy (removal of the appendix), hysterectomy (removal of the uterus), abdominal hernia repair, and bladder suspension (replacement of a sagging bladder into the normal position). BT reported a family history of heart disease, hypertension, and cancer (MMH, 2012). BT has 4 children, 2 sons and 2 daughters. While caring for BT, I had the pleasure to meet one of her sons, a daughter, and a granddaughter. Many of her family members are also missionaries and the granddaughter that I met has served her current mission in Paraguay for 11 years. She is retired and insured through Medicare; she has a living will, her son is executor, and she is full code unless it is going to be prolonged.
Medical History BT denied use of tobacco or alcohol and stated that she has never used any type of illegal substances. She lives with her husband and prior to her admission she was able to provide 100% of her care at home, including activities of daily living (ADL’s). She is able to walk unaided and she stated that she does not normally have any shortness of breath (SOB), chest pain, nausea, vomiting, or abdominal pain or distention. There has not been any dramatic change in her weight prior to admission and no evidence of edema. Past medical history includes hypertension, asthma, hyperlipidemia, coronary artery disease in which she suffered a myocardial infarction in 2006 and received cardiac catherization, transient ischemic attack, and
Medical History BT denied use of tobacco or alcohol and stated that she has never used any type of illegal substances. She lives with her husband and prior to her admission she was able to provide 100% of her care at home, including activities of daily living (ADL’s). She is able to walk unaided and she stated that she does not normally have any shortness of breath (SOB), chest pain, nausea, vomiting, or abdominal pain or distention. There has not been any dramatic change in her weight prior to admission and no evidence of edema. Past medical history includes hypertension, asthma, hyperlipidemia, coronary artery disease in which she suffered a myocardial infarction in 2006 and received cardiac catherization, transient ischemic attack, and
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