Assessment Description
“Fever of unknown origin” is a diagnosis known well to acute care providers. “Rash of unknown origin” is not an official diagnosis, but it is one that you will often encounter.
Imagine that during a shift a nurse calls you to the bedside to look at a “new rash” that a patient has developed over the past 4 hours.
Conduct research and locate a picture of a rash. Design a brief case study to describe the rash. Provide basic information that your classmates will need to problem-solve, diagnose, and treat the rash. Post the case study and associated picture for your classmates.
Select one of the case studies created by your classmates and explain how you will diagnose and treat the rash. Include discussion of additional referrals or consultations that might be necessary. Support your answer with two or three peer-reviewed resources.
You are the AGACNP working for a hospitalist group. You receive a call from a busy general surgeon who just performed an elective laparoscopic cholecystectomy on a patient he was planning on discharging home after the procedure. However, he has been notified that the patient developed “some kind of rash” and consults you for medical management. He has not seen the patient since she left the OR; both he and the anesthesia provider are in another surgical case (which he expects to take 2-3 hours to complete).
You arrive in the PACU and locate the patient. You find her sitting up in the gurney, scratching at her abdomen, off the monitor. She is awake and oriented x 4 though a bit groggy still from anesthesia. She is a 32 year old Hispanic female with a past medical history of cholelithiasis; her only home medication is an oral combined estrogen/progestin contraceptive which she takes daily. She has never had surgery or general anesthesia, until today. The EHR states a penicillin allergy; when you question her about it, her reply is, “I was given penicillin when I was a baby so I don’t know what happened.” Upon inspection of her chest and abdomen, you find multiple raised, reddened, and edematous plaques which she describes as “itchy.” VS taken 5 minutes prior to your arrival are: HR 81, BP 128/62, RR 14, T 98.4, O2 98% on RA, pain “0/10”.
You review the anesthesia and PACU records. Since arrival to pre-op, the patient has received the following IV medications:
NS continuous infusion
Sevoflurane
Cistracurium
Propofol
Cefazolin
Ondansetron
Fentanyl
Glycopyrrulate
Neostigmine
Morphine
You have just finished your interaction (which was largely unremarkable) with the patient when she takes a phone call on her cell phone. You notice her phonation sounds different. You look over at her and see her lips are now swollen. You ask her to open her mouth, her tongue has become edatemous, and you can now clearly hear expiratory wheezing, even without your stethoscope.
1. What are your priority treatment interventions?
2. Who else should be notified of this developing situation?
3. The medications given are all commonly administered to perioperative patients. Review these drugs, and discuss which you think most likely contributed to the allergic reaction and why.
4. Discuss why the patient would be given cefazolin if she reported a childhood pencicillin allergy with an unknown reaction. Include the risks and benefits of administering cefazolin in this scenario.
5. This was an elective procedure with an anticipated postoperative home discharge. The hospital is full and no beds are currently available. What is this patient’s disposition? Can she be discharged home today? Why or why not?
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