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NR 601 Week 5 Case Study Discussion

NR 601 Week 5 Case Study Discussion

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NR 601 Week 5 Case Study Discussion

NR 601 Week 5 Case Study Discussion

NR 601 Week 5 Case Study Discussion – Part One

NR 601 Week 5 Case Study Discussion – Part One – C.W. is a tall, thin 78-year-old African American male brought into the office by his son who states that the patient is restless, angry, and has been unable to sleep for the last week. The son indicates that he is very concerned about his father because he lives alone. Also, he is concerned about the “strange” symptoms that his father has presented with recently.

 Background: 

C.W. presents as restless, hyperverbal, obnoxious and angry. He expresses himself byperiodic yelling. He is unkempt and smells strongly of urine, alcohol and body odor. ………… has an unsteady gait and sways while standing. As you converse with the son, you determine that C.W. was medically separated from military service due to mental health issues after 2 years of active duty that ended in 1947. He has been married and divorced three times over the years. He typically seeks no acute or preventative medical care. ___ was treated by a psychiatrist previously, but he did not like taking the prescribed medications so he stopped taking them and did not keep any further psychiatric appointments. NR 601 Week 5 Case Study Discussion.

 PMH:

Patient denies any previous diagnoses. However, when asked why he saw a psychiatrist in the past, he tells you that the psychiatrist diagnosed paranoid schizophrenia, but that he does not have any psychiatric diagnoses or problems. He states: “It was just a way for him to make money off me coming in and seeing him and paying the drug companies for me to take all those meds!”

Current medications: 

Denies prescription medications, over the counter medication, herbal therapies or vitamins.

Surgeries:

Denies surgeries

Allergies: NKA

Vaccination History:

Flu vaccine: never given

Pneumovax: never given

Tetanus: never given

Herpes zoster: never given

Screening History:

Last Colonoscopy was 2012-normal

Last dilated retinal and glaucoma exam was 2013

 Social history and Risk Factors:

Patient admits to smoking cigarettes and cigars. …… estimates that he smokes about 1 pack of cigarettes daily for the last 40 years, and 2 cigars each week for the last 30 years.

He states that he drinks a 24 ounce bottle of beer 4-6 times a week. … denies drinking wine or hard liquor. …….. does admit to smoking marijuana on occasion but does not use other recreational drugs. NR 601 Week 5 Case Study Discussion.
Patient denies falling. You notice some scrapes on his forearms, and when asked, he tells you that he fell yesterday: “I got pretty drunk out fishin’ with friends and fell off my bike trying to ride home”. He does not use any assistive devices for ambulation or balance.

Significant ROS:

Productive cough with white sputum. Denies hemoptysis.

He answers “No” to the PHQ-2 screening questions.

Family history:

Reports no significant family history

Discussion Part One:

  • Provide differential diagnoses (DD) with rationale.
  • Further ROS questions needed to develop DD.
  • Based on the patient data provided, choose geriatric assessment tools that would be appropriate to use in conducting a thorough geriatric assessment. Provide a rationale on why you are choosing these particular tools.

NR 601 Week 5 Case Study Discussion Part Two (graded)

Physical examination:

Vital Signs:

Height:  5’8”   Weight: 154 pounds BMI: 23.4   BP: 132/76    P: 76

regular    R: 16

HEENT: Normocephalic, symmetric. PERRLA, EOMI, no cataracts noted; poor dentition.

NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. NR 601 Week 5 Case Study Discussion.

LUNGS: Respirations are unlabored, decreased breath sounds and crackles at the bases bilaterally. Prolonged expiratory phase throughout lung fields, inspiratory wheezes and a productive cough of cloudy white sputum.

HEART: RRR with regular without S3, S4, murmurs or rubs.

ABDOMEN: Round, firm abdomen; active bowel sounds;  non-tender.

NEUROLOGIC: Unsteady gait, swaying while standing during periods of agitation. Achilles reflexes are present bilaterally. Strength is equal but decreased in the upper and lower extremities bilaterally.

GENITOURINARY:  Urinary incontinence with strong odor of urine. NO CVA tenderness.

MUSCULOSKELETAL: Mild kyphosis. Heberden’s nodes at the distal interphalangeal joints (DIP) of all fingers, and marked crepitus of the bilateral knees on flexion and extension. Pedal pulses palpable. No edema noted in lower extremities. NR 601 Week 5 Case Study Discussion.

PSYCH: Manic, restless, angry and hyperverbal

SKIN: Right forearm with 3 cm x 5 cm x 0 cm dry, scabbed abrasion. Left forearm with 4 cm x 5 cm x 0 cm dry, scabbed abrasion. NR 601 Week 5 Case Study Discussion.

NR 601 Week 5 Case Study Assignment Self Check Spring 2018

Purpose
The purpose of this case study assignment is to
  1. Analyze provided subjective and objective information to diagnose and develop a management plan for the case study patient.
  2. Apply national diabetes guidelines to case study patient management plan.
  3. Demonstrate mastery of SOAP note writing.

Preparing The Assignment
The assignment is a paper which is to be written in APA format. This includes a title page and reference page. The paper shall not exceed 20 pages. Review the attached patient visit information. The patient has presented for an acute care visit. You are provided with the subjective and objective exam findings. As the provider, you are to diagnose and develop the management plan for this case study patient. Use the categories below to create section headings for your paper. Review the APA manual for paper format instructions.
  • Introduction: Briefly discuss the purpose of this paper.
  • Assessment: Review the provided case study information.
Identify the primary, secondary and differential diagnoses for the patient. Use the 601 SOAP note format as a guide to develop your diagnoses. Each diagnosis will include the following information:
  1. ICD 10 code.2.A brief pathophysiology statement which his no longer that
  2. Sentences, paraphrased and includes common signs and symptoms of the diagnosis.
  3. The patient’s pertinent positive and negative findings, including a brief 1-2 sentence statement which links the subjective and objective findings (including lab data and interpretation). NR 601 Week 5 Case Study Discussion.
  4. A rationale statement which summarizes why the diagnosis was chosen.
  5. Do not include quotes, paraphrase all scholarly information and provide an intext citation to your scholarly reference. Use the Reference Guidelines document for information on scholarly references.

NR 601 Week 5 Case Study Discussions Physical Examination​ (Part-1) NEW

Discussion Part One (graded)

C.W. is a tall, thin 78-year-old African American male brought into the office by his son who states that the patient is restless, angry, and has been unable to sleep for the last week. The son indicates that he is very concerned about his father because he lives alone. Also, he is concerned about the “strange” symptoms that his father has presented with recently. NR 601 Week 5 Case Study Discussion.

Background: 

C.W. presents as restless, hyperverbal, obnoxious and angry. He expresses himself by periodic yelling. He is unkempt and smells strongly of urine, alcohol and body odor. ………… has an unsteady gait and sways while standing. As you converse with the son, you determine that C.W. was medically separated from military service due to mental health issues after 2 years of active duty that ended in 1947. He has been married and divorced three times over the years. He typically seeks no acute or preventative medical care. ___ was treated by a psychiatrist previously, but he did not like taking the prescribed medications so he stopped taking them and did not keep any further psychiatric appointments.

PMH:

Patient denies any previous diagnoses. However, when asked why he saw a psychiatrist in the past, he tells you that the psychiatrist diagnosed paranoid schizophrenia, but that he does not have any psychiatric diagnoses or problems. He states: “It was just a way for him to make money off me coming in and seeing him and paying the drug companies for me to take all those meds!” NR 601 Week 5 Case Study Discussion.

Current medications: 

Denies prescription medications, over the counter medication, herbal therapies or vitamins.

Surgeries:

Denies surgeries

Allergies: NKA

Vaccination History:

Flu vaccine: never given

Pneumovax: never given

Tetanus: never given

Herpes zoster: never given

Screening History:

Last Colonoscopy was 2012-normal

Last dilated retinal and glaucoma exam was 2013 

Social history and Risk Factors:

Patient admits to smoking cigarettes and cigars. …… estimates that he smokes about 1 pack of cigarettes daily for the last 40 years, and 2 cigars each week for the last 30 years.

He states that he drinks a 24 ounce bottle of beer 4-6 times a week. … denies drinking wine or hard liquor. …….. does admit to smoking marijuana on occasion but does not use other recreational drugs.
Patient denies falling. You notice some scrapes on his forearms, and when asked, he tells you that he fell yesterday: “I got pretty drunk out fishin’ with friends and fell off my bike trying to ride home”. He does not use any assistive devices for ambulation or balance. NR 601 Week 5 Case Study Discussion. NR 601 Week 5 Case Study Discussion.

Significant ROS:

Productive cough with white sputum. Denies hemoptysis.

He answers “No” to the PHQ-2 screening questions.

Family history:

Reports no significant family history

Discussion Part One:

  • Provide differential diagnoses (DD) with rationale.
  • Further ROS questions needed to develop DD.
  • Based on the patient data provided, choose geriatric assessment tools that would be appropriate to use in conducting a thorough geriatric assessment. Provide a rationale on why you are choosing these particular tools.

Introduction

The purpose of this paper is to review the patient’s subjective and objective information from the visit, and analyze the information to formulate an appropriate diagnosis; then develop an evidence based plan of care for the patient, by applying the National Diabetes Guidelines to the care for mature and aging families…………….. I will demonstrate comprehensive knowledge and proficiency on my ability to correctly write a SOAP note.

Assessment

Primary Diagnosis: Diabetes (E10.9) Pathophysiology of diabetes type I is insulin dependent, this is the inability of the pancreatic beta cells to produce insulin due to autoimmune destruction; type II, the pancreas does not produce enough insulin needed by the body, or the body is unable to use insulin properly (American Diabetes Association, 2017). Symptoms: fatigue, excessive thirst, hunger, and frequent urination.
Secondary Diagnosis: Hyperlipidemia (E78.5) Pathophysiology of hyperlipidemia is the increase in the plasma lipid levels by the over production of TG-rich lipoproteins in the liver (Shattat, 2014). Symptoms: Typically does not have any symptoms.
Hypertension (I15.2) Pathophysiology of hypertension is the increase in the vascular resistance, stiffness, and the vascular system to respond to stimuli (Delacroix, Chokka & Worthley, 2014). Symptoms: Typically have no symptoms………………………., back and joint aches, and overweight.
Left knee arthritis (M19.072) Pathophysiology of osteoarthritis-cartilage loss and the thickening of the subchondral plate, and production of new bone in the joint spaces (Ashkavand, Malekinejad & Vishwanath, 2013). Symptoms: Joint pain, stiffness, swelling, and tenderness. NR 601 Week 5 Case Study Discussion.
Differential Diagnosis: Proteinuria (R80.9) Pathophysiology of proteinuria is structural damage to the kidneys, glomerular membrane, and tubulointerstitial tissue from an alteration in of metabolic changes such as hyperglycemia, hyperlipidemia, and hypertension, causing an increase in the urinary albumin (Shen, Fang, Xing & Wang, 2017). Symptoms: Protein in urine, hypertension, and increase need to urinate, fatigue, weight gain from fluid retention, foamy urine, and swelling in the face and extremity.
            I chose each diagnosis based of the CC and labs that were both subjective and objective findings. The patient has an Hgb A1C of 7.7 and glucose in her urine which indicate diabetes, according to the (American Diabetes Association, 2016) an A1C of 6.5 or greater meets the criteria for diabetes, to confirm the patient’s diagnosis she will need to repeat the A1C. She also has symptom of diabetes such as fatigue, excessive thirst, hunger, and frequent urination. Mrs. G blood pressure is 130/82, which is considered stage I hypertension according to the (American College of Cardiology, 2017); systolic pressure 130-139 or diastolic 80-89. Her triglycerides are 232, LDL 143, HDL 37, TC 228; the normal for triglycerides should be between 50-150, LDL should be less than 100, and HDL should be greater than 40, and the TC should be less than 200, this would indicate hyperlipidemia (American Diabetes Association, 2017). The patient is 5’2 and weighs 190 pounds which gives her a BMI of 34.8, a BMI of 30-35 or greater is classified as Obesity (Nuttall, 2015). The patient has protein in her urine which could be an indicator of proteinuria or kidney disease; she also has symptoms of proteinuria which includes protein in urine, hypertension, and increase need to urinate, fatigue, weight gain (Shen, Fang, Xing & Wang, 2017). The patient has a history of arthritis, as well as obesity; some contributing factors to osteoarthritis are obesity, age, women are more at risk, and a sedentary lifestyle (Ashkavand, Malekinejad & Vishwanath, 2013) NR 601 Week 5 Case Study Discussion.
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