A 24-year-old female presents with dizziness, lightheadedness, fatigue, and headaches.
Answer
SUBJECTIVE:
She reports nausea and vomiting over the past 12 hours, with no diarrhea. She as been unable to keep down fluids and denies fever or chest pain. Dizziness began after vomiting episodes started 12 hours ago. She has been lying down most of the time since onset; nausea persists. She complains of mild crampy epigastric discomfort, coldness, shakiness. She has no history of recent trauma nor no chronic illnesses. She takes birth control pills. No known allergies or significant past medical history.
OBJECTIVE:
Vital Signs:
Temperature: 98.96 F Heart rate: 108 bpm Blood pressure: 88/56 mmHg Respiratory rate: 18/min O2 sat: 98% on room air
Physical exam:
General: Lying down and tired
HEENT: Mildly dry mucous membranes, no scleral icterus
Cardiovascular: Regular rhythm without murmurs.
Abdomen: Mild epigastric tenderness, no rebound/guarding, normal bowel sounds.
Neuro: Alert and oriented x 3, No focal deficits
Extremities: Mildly decreased skin turgor, delayed capillary refill.
Orthostatic: BP drop of 20 mmHg systolic with dizziness
ASSESSMENT:
Hypovolemia secondary to vomiting and reduced oral intake
Hypokalemia from vomiting and reduced intake
Anxiety or panic disorder
PLAN:
IV normal saline or Lactated Ringer's for fluid resuscitation
Check complete blood count (CBC)
Correct potassium if low
Tramadol for headaches
Order pregnancy test
Workup for cardiovascular and neurological if dizziness persists. EKG, stress test, and neurological exam
Nursing priorities:
Maintain airway, breathing, and circulation
Prevent falls due to dizziness
Monitor for signs of shock or arrhythmia
Educate on recognizing dehydration symptoms and when to seek care