NSG 6420: Family Health Adult and Gerontology Papers and Case Study

NSG 6420: Family Health Adult and Gerontology Papers and Case Study

Provider: Nurse Practitioner: Family Health Adult and Gerontology

 SOAP Note Case Study

Mr. D. is a 72 y.o. male who presents to your practice for a routine physical examination. During the review of systems, he reports getting up to urinate on average three times nightly. He comments that it is getting very annoying and he has cut back on his fluid intake after dinner, including his usual glass of wine, but the problem persists. He denies any burning with urination and has not noticed any blood in his urine. His bowels are regular and he has not made any changes in his diet. NSG 6420: Family Health Adult and Gerontology Papers and Case Study

Chronic health problems include hypertension, dyslipidemia, and osteoarthritis.

Medications: valsartan and hydrochlorothiazide 80/12.5, one tablet daily in a.m., acetaminophen arthritis, one to two tablets occasionally for arthritic pain, atorvastatin 10 mg PO daily in the evening.

NSG 6420: Family Health Adult and Gerontology Papers and Case Study

Vital signs: Blood pressure 130/82, pulse 74 (regular), respiratory rate 16, temperature 98.6ºF orally, BMI 24.5

Chief Complaint: Urinating three times at night

 

Case Study Overview and Rubric

NSG 6420: Family Health Adult and Gerontology Papers and Case Study

Provided pertinent subjective (HPI, Medications/Allergies, PMH, PSH, social history, family history) data and rationale
Provided pertinent objective data (vitals, physical exam) and rationale
Discussed appropriate differential diagnoses and rationale
Discussed the plan of care including any diagnostics, medications education, and follow-up/referral
Discussion of national guidelines in plan of care
Use of correct grammar, scholarly/professional vocabulary, cited all sources using APA format

 NSG 6420: Family Health Adult and Gerontology Case Study

Overview:

The Case study is to be written as a formal paper in APA format. Make sure you include all areas included in the rubric. You may want to view this more as a research paper. You need to do a review of the literature and include at least 3 peer-reviewed journal articles and all pertinent evidenced based guidelines. The guidelines need to be from the original source. It is not satisfactory to simply site Up-to-date as a guideline. You must use the national guideline pertinent to the diagnosis. You need to include a thorough/comprehensive discussion of differential diagnoses and discuss for each of these differential diagnoses what subjective and objective data and diagnostics you would use to be able to determine your actual diagnosis. Then pick your top three likely diagnoses and discuss the plan of care for each of them. Make sure to include the rationale so that I can see your critical thinking process. Do not make any assumptions. Include the rationale. NSG 6420: Family Health Adult and Gerontology Papers and Case Study

 

 

Subjective:

The subjective section must include all of the following areas: HPI, PMH, Past surgical history, Family history, Social history, medications, allergies, and ROS. For each of these sections, you need to discuss what further information you would need to gather from the patient beyond what is given in the written case study in the book. Giving me the information from the book will not get you any points. You must think beyond what the book gives you in the case.

 

HPI (5 points): You must discuss all chief complaints presented if there is more than one. You must include a thorough discussion of each component of the HPI specific to the chief complaint. Do not just list out what PQRST means. You must think beyond asking those generic questions and make them meaningful to the case and include your rationale.

 

PMH (2 points): Discuss any past medical history given in the case (why it is pertinent) and what specifically you would ask the patient about their PMH during their visit. Include your rationale.

 

Past Surgical History (2 points): Discuss any past surgical history given in the case and why it is pertinent. Discuss what you would specifically ask the patient about their surgical history during their visit and include your rationale.

 

 

Family History (1 point): Discuss any family history given in the case and why it is pertinent. Discuss what you would specifically ask the patient about their family history during their visit and include your rationale.

 

Social History (1 point): Discuss any social history given in the case and why it is pertinent. Discuss what you would specifically ask the patient about their social history during their visit and include your rationale.

 

Medications (2 points): Discuss any medications given in the case and why it is pertinent. Discuss what you would specifically ask the patient about their medications during their visit and include your rationale.

 NSG 6420: Family Health Adult and Gerontology Case Study

Allergies (2 points): Discuss any allergies given in the case and why it is pertinent. Discuss what you would specifically ask the patient about their allergies during their visit and include your rationale.

 

Review of Systems (5 points): Include a thorough review of systems pertinent to the case with supporting rationale. ROS includes both general or constitutional complaints as well as a review by body system. DO NOT just include a comprehensive ROS. Include the pertinent aspects relative to the case with supporting rationale.

NSG 6420: Family Health Adult and Gerontology Papers and Case Study

 Objective: The objective section should include discussion of the vitals and the objective data given in the case and why it is pertinent in determining your differential and all areas you would assess in your physical exam of the patient pertinent to the case. It should be a discussion of a focused exam of the patient pertinent to the case with supporting rationale. Include any missing vitals that you would want to obtain and why.

 

Differential Diagnoses: A comprehensive list of differentials should be provided with rationale. Include at least 6 and no more than 10 differentials. For each differential, include a discussion of what subjective and objective data and diagnostics you would use to be able to rule that diagnosis in or out. Then pick your top three diagnoses and include a rationale for why you chose them.

Treatment Plan: The treatment plan must include a thorough discussion of diagnostics, medications, education, and follow-up/referral for each of the top 3 differentials with supporting rationale. The diagnostics discussion should not be limited to the top 3 differentials. It should encompass diagnostics pertinent to the differentials discussed.

NSG 6420: Family Health Adult and Gerontology Papers and Case Study

Guidelines: Guidelines specific to the top three differential diagnoses should be discussed related to each aspect of the plan of care (medications, diagnostics, education, referral/follow-up).

	10	8	6	4	2
Guidelines	Complete and thorough discussion of all pertinent guidelines for all three top differential diagnoses	Missing 25% of pertinent discussion of guidelines	Missing 50% of pertinent discussion of guidelines	Missing 75% of pertinent discussion of guidelines	Missing 90% of pertinent discussion of guidelines

NSG 6420: Family Health Adult and Gerontology Papers and Case Study

 

Technical Aspects/Format/APA: The case study should be written as a formal paper in APA format. The paper should be written using proper grammar and scholarly/professional vocabulary. Plagiarism is prohibited. In order to help decrease the likelihood of plagiarism, a turn-it-in score in the green will be required. A turn-it-in score in the green does not mean that plagiarism has not occurred. If you take a sentence or phrase exactly as written from another source, you must cite accordingly with quotations and the page number (see APA guidelines). When you paraphrase, you must still cite your source (author, page number). Please review your APA guidelines so that you cite appropriately. A turn-it-in score not in the green will not be accepted. If you submit a paper with a turn-it-in score not in the green, you will be allowed up to 48 hours to resubmit. Papers not resubmitted within 48 hours will forfeit a score of 0.

NSG 6420: Family Health Adult and Gerontology Case Study

	10	8	6	4	2
Structure of paper/ grammar/ APA	Complete adherence to APA guidelines	Missing 25% of APA compliance	Missing 50% of APA compliance	Missing 75% of APA compliance	Missing 90% of APA compliance

 

 

Subjective

Chief Complaints:

• Patient statement: “For almost 2 weeks, I have been coughing a dry and non-productive cough, and I feel some chills”.

History of Present Illness:

• This is 59 old African American man who is received in the clinic complaining of cough that has been going on for almost 2 weeks. The patient describes a dry and non-productive cough that mainly take place at night and has caused him pain at the central of the chest. He stated he is short of breath and that he is not able to sleep on his bed but on his chair because it is easier for him to breath and catch some sleep while sitting on the chair. He reported the short of breast is increased with activity such moving the chair close to the bed. He reported sore throat in the morning. He reported that his cough along with being tired, fatigued, anxious and feeling chilly breeze have been worsening the last 3-4 days. He took his inhaler for his emphysema last night and is here today to seek medical attention. NSG 6420: Family Health Adult and Gerontology Papers and Case Study

Past Medical History:

• Diabetes Type II
• Emphysema

Past surgical History:

• None

Family History:

• One older brother, one living with osteoporosis and hypertension at age 65. NSG 6420: Family Health Adult and Gerontology Case Study
• One young sister is alive and well.
• Father is alive and healthy
• Mother is alive with diabetes Type II

Social History:

• Not married but single with 1 child of 27 years old.
• Drug: No illicit drugs
• Smoking: 1 pack a day
• Alcohol: 1- 2 beers on the week-end

Medications:

• Tylenol 650 mg PO Q4 hours PRN for pain
• Metformin 500 mg BID
• Combivent Inhaler 2 puff Q4 hours PRN

NSG 6420: Family Health Adult and Gerontology Case Study

Allergies:

• Sulfa: cause him rash and itching

           Review of system

General:

• African American male reports unintentional weight gain, recently. Reports fatigue.

HEENT:

• Denies any headache, impaired vision or hearing, discharge, or ringing.
• Denies any nose bleeds, nasal stuffiness.
• Denies lymphadenopathy or thyromegaly.
• Denies any loose teeth or bleeding gum.
• Denies any pain or difficulty swallowing.
• Report sore throat in the morning

Cardiovascular:

• Report slight chest pain at the center after night coughing

Respiratory:

• Reports short of breath. NSG 6420: Family Health Adult and Gerontology Case Study

Gastrointestinal:

• Denies any pain abdominal pain.
• Denies any abnormal bowel movement or bloody stools
• Denies nausea or vomiting

Genitourinary:

• Denies any dysuria, hesitancy, or urinary abnormalities.

Integumentary:

• Denies any lesions, moles, bruises.

Musculoskeletal:

• Denies swelling, stiffness, or decreased joint motion.

Endocrine/Hematologic:

• Denies any endocrine or hematologic disorder.

Musculoskeletal:

• Denies swelling, stiffness, or decreased joint motion.

Endocrine/Hematologic:

• Denies any known endocrine or hematologic disorder. NSG 6420: Family Health Adult and Gerontology Case Study

Immunization/Prevention:

• Not up to date

Neurological/Psychologic:

• Denies any motor, reflexes, sensory, coordination, or gait deficits.
• Denies any depression or hallucinations or mental issues.

   Objective NSG 6420: Family Health Adult and Gerontology Papers and Case Study

Vital Signs:

• BP: 138/62, T: 101 orally, P: 100, R: 20, Weight: 139, Height: 5’3”, BMI: 30.21, Temp 100.1. Saturation 91% RA.

Constitutional:

• Pleasant African American male, cooperative, articulate, and appropriately dressed for fall-winter weather.

HEENT:

• Head: Good hair distribution. No lesions at the scalp.
• Eyes/Ear: No vision or hearing impairments noted. Wears reading glasses
• Nose: No frequent nasal congestion/stuffiness or nosebleeds.
• Uvula is on midline
• Pharynx is noticeably without erythema, edema or exudate. No presence of odor is noted.
• Neck is supple, and non-tender
• Trachea is on midline.
• Thyroid palpation is non-enlarged, non-tender, and no presence of mass or nodule noted. NSG 6420: Family Health Adult and Gerontology Case Study

Lymph Nodes:

• No nodules present.

Carotids:

• No JVD. Mild AV nicking.

Lungs:

• Wheezes bilaterally at the upper lobes
• Diminished breath sounds to auscultation at lower lobes.
• Positive for short of breath
• lung wall yields no abnormal findings. NSG 6420: Family Health Adult and Gerontology Papers and Case Study

Heart:

• Heart Rate is irregular with no murmurs or gallops.

Abdomen:

• Soft, non-tender with active bowel sounds in all 4 quadrants
• No abdominal bruits.

Genitourinary:

• Deferred.

Rectal:

• Deferred

Extremities/Pulses:

• Pulses normal and present throughout. No edema.

Neurologic/Psychic:

• Alert and oriented x 3.
• CN II-XII tested intact.
• Strength and sensation symmetric and intact.
• Appropriate and aware of surroundings

Diagnostic Test:

• EKG: Normal Regular Sinus Rhythm
• Chest X ray: Hyperinflation of both lungs and an increased anterior-posterior chest wall diameter.

Assessment

• COPD – J44.9:
• Asthma – J45.909:
• Stable angina pectoris – I20.9:

Diagnosis Differential:

1-Acute coronary syndrome – I24.9: Even though there is presence of exacerbation of short of breath, there is no chest pain radiating to both arms which is persistent in ACS. Additionally, ACS has chest pain associated with diaphoresis. We can fairly rule it out.

2-Pleural Effusion – J91.8: X Ray does not show any blunting of the right and left costophrenic angles which is highly considered a suspicious of pleural effusion (Blanchette, Grenier, 2014). Chest X ray shows hyperinflation of both lungs and an increased anterior-posterior chest wall diameter. Despite of some similarities, per chest X ray, patient may not have pleural effusion. NSG 6420: Family Health Adult and Gerontology Papers and Case Study.

3-Pulmonary embolism – I26. 9: Symptoms as increased or irregular heartbeat, difficulty catching breath, which may develop either suddenly. Chest pain that is sharp and stabbing. It is a medical emergency. We can rule it out as well.

Agreeing with the patient’s problems as listed in the assessment and ruling out those of the diagnostic differentials, will now conduct a plan of care as below.

Plan of Care

COPD – J44.9: Difficulty in emptying air out of the lungs (airflow obstruction) can lead to shortness of breath or feeling tired because you are working harder to breathe. COPD is a term that is used to include chronic bronchitis, emphysema, or a combination of both conditions (American thoracic society, 2018). Symptoms are persistent to COPD and patient has history of emphysema and he is a smoker. This our primary diagnosis. A recent chest x-ray also showed evidence of emphysema with hyperinflation of both lungs and an increased anterior-posterior chest wall diameter. The plan of care is very much about the COPD which, we believe is this patient main problem.

• The patient reported that she was previously given samples of an inhaler for management of her emphysema symptoms.  The National Institutes of Health (NIH) (2013) recommend an inhaled bronchodilator for management of emphysema symptoms.  Bronchodilators relax the muscles around your airways, which makes breathing easier. Combivent is used as an inhaled medication to prevent bronchospasm in people with chronic obstructive pulmonary disease (COPD) who are also using other medicines to control their condition (drugs.com, 2014). NSG 6420: Family Health Adult and Gerontology Papers and Case Study.

Asthma – J45.909: It’s a disease where it is difficult to empty the air out of the lungs, and It is not uncommon, however for a patient with COPD to also have some degree of asthma. flare-ups or asthma attacks are often caused by allergies and exposure to allergens such as pet dander, dust mites, pollen or mold. Non-allergic triggers include smoke, pollution or cold air or changes in weather.

• Plan of care will have the same as above which is our primary diagnostic. We will not focus on the asthma as a problem for the patient but will cover some related asthma issues that are present in COPD.

Stable angina pectoris – I20.9: As patient’s symptoms include midsternal chest pain described as a tightness and pressure that radiated down left arm. As Talbert stated, “there are three factors that determine myocardial oxygen demand: heart rate, contractility, and intra-myocardial wall tension, with the latter considered the most important” (Talbert, 2011).

• Will not consider it in the care plan as it is not relevant for this patient case.

Considering the plan, we will have as follow:

Medication:

• Oxygen: Administration of oxygen can help the patient breathe better even though COPD patient runs low on oxygen saturation: 2 LNC.
• Combivent: 2 puff Q4 hours as needed.
• Advair (fluticasone and salmeterol): 1 puff q4 hours PRN is recommended to prevent flare ups or worsening of COPD associated with chronic bronchitis or emphysema (drugs.com, 2015).
• Azithromycin 250 mg Po BID, patient has low grade fever. Do not want to miss a possible underneath pneumonia. NSG 6420: Family Health Adult and Gerontology Papers and Case Study
• Percocet 5/325 mg PO Q4H for pain

Will order blood work and tests

• CBC, CMP, Lipid Panel, Liver Function Panel, BNP.

Education:

• Educate patient on the possibility of worsening depression even on medication.
• Educate patient that treatment can take up to 8 weeks to take full effect, so she should not be discouraged if she does not suddenly feel better.
• Suppression of allergens, environmental or seasonal
• Educate patient on particular pursed lip breathing techniques.
• Exercise regularly
• Reduce total daily intake of calories to lose weight or maintain healthy weight eventually.
• Reduce alcohol intact as appropriate.
• Smoking cessation, support and help will be provided: Nicotine patch or Chantix.
• Will advise patient to be up to date for his immunization: Flu and Pneumonia vaccines.

NSG 6420: Family Health Adult and Gerontology Case Study

• At this present time, there is no cardiac issue that warrants a cardiology work up.
• Will see patient in 2-10 weeks, if no improvement will refer patient to a lung doctor.
• Referral: The patient may need to follow up with a Pulmonologist for the management of her COPD.

  Clinical Reflection

Without a doubt, Chronic obstructive pulmonary disease (COPD) is a global problem and a major cause of chronic morbidity and mortality (Global initiative for chronic obstructive lung disease, GOLD 2016). Thus, as nurse practitioner we are going to play a central role in taking care of those patients living in the conditions of COPD. Reports show a need to structure the care of patients with COPD in primary health care. So, as it is in this patient, it is imperative to emphasize an important point which is each individual is different and complex. The challenge of individualizing care expressed the importance of cooperation with other professions in the care of patients with COPD. And that, once the patient feels she is in a place to seek outside help, she should definitely consider local resources in her neighborhood for support.

Should no improvement be noticed and despite all efforts, a referral to the pneumologist is highly recommended.

  References

American Thoracic Society. (2018). Chronic Obstructive Pulmonary Disease (COPD). Retrieved

from http://www.thoracic.org/patients/patient-resources/resources/copd-intro.pdf

Drugs.com. (2016). Tessalon – FDA prescribing information, side effects and uses. Retrieved

from https://www.drugs.com/pro/tessalon.html

Drugs.com. (2015). Levofloxacin: Indications, Side Effects, Warnings – Drugs.com. Retrieved

NSG 6420: Family Health Adult and Gerontology Papers and Case Study

from https://www.drugs.com/cdi/levofloxacin.html

National Institutes of Health. (2013). How Is COPD Treated? Retrieved from

http://www.nhlbi.nih.gov/health/health-topics/topics/copd/treatment

Talbert, L. (2011). Chapter 23. Ischemic heart disease. In: Talbert RL, DiPiro JT, Matzke GR, et

al (Eds), Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York, NY:

McGraw-Hill; 2011.

NSG 6420: Family Health Adult and Gerontology Papers and Case Study