NRNP 6540 Week 5 Case Assignment

Assignment: Assessing, Diagnosing, and Treating Head, Neck, and Face Disorders

To prepare:

• Review the case study provided by your Instructor.
• Reflect on the patient’s symptoms and aspects of disorders that may be present.
• Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
• Access the Focused SOAP Note Template in this week’s Resources.

The Assignment:

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

• Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
• Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
• Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
• Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition form

Also Read: SOAP Note Writers

Week 4 Case Title: A 67-year-old With Tachycardia and Coughing

Ms. Jones is a 67-year-old female who is brought to your office today by her daughter Susan. Ms. Jones lives with her daughter and is able to perform all activities of daily living (ADLs) independently. Her daughter reports that her mother’s heart rate has been quite elevated, and she has been coughing a lot over the last 2 days. Ms. Jones has a 30-pack per year history of smoking cigarettes but quit smoking 3 years ago. Other known history includes chronic obstructive pulmonary disease (COPD), hypertension, vitamin D deficiency, and hyperlipidemia. She also reports some complaints of intermittent pain/cramping in her bilateral lower extremities when walking and must stop walking at times for the pain to subside. She also reports some pain to the left side of her back, and some pain with aspiration.

Ms. Jones reports she has been coughing a lot lately, and notices some thick, brown-tinged sputum. She states she has COPD and has been using her albuterol inhaler more than usual. She says it helps her “get the cold up.” Her legs feel tired but denies any worsening shortness of breath. She admits that she has some weakness and fatigue but is still able to carry out her daily routine.

 Vital Signs: 99.2, 126/78, 96, RR 22 

Labs: Complete Metabolic Panel and CBC done and were within normal limits

CMP Component	Value	CBC Component	Value
Glucose, Serum	86 mg/dL	White blood cell count	5.0 x 10E3/uL
BUN	17 mg/dL	RBC	4.71 x10E6/uL
Creatinine, Serum	0.63 mg/dL	Hemoglobin	10.9 g/dL
EGFR	120 mL/min	Hematocrit	36.4%
Sodium, Serum	141 mmol/L	Mean Corpuscular Volume	79 fL
Potassium, Serum	4.0 mmol/L	Mean Corpus HgB	28.9 pg
Chloride, Serum	100 mmol/L	Mean Corpus HgB Conc	32.5 g/dL
Carbon Dioxide	26 mmol/L	RBC Distribution Width	12.3%
Calcium	8.7 mg/dL	Platelet Count	178 x 10E3/uL
Protein, Total, Serum	6.0 g/dL
Albumin	4.8 g/dL
Globulin	2.4 g/dL
Bilirubin	1.0 mg/dL
AST	17 IU/L
ALT	15 IU/L

Allergies: Penicillin: hives

Current Medications:

• Atorvastatin 40mg p.o. daily
• Multivitamin 1 tablet daily
• Losartan 50mg p.o. daily
• ProAir HFA 90mcg 2 puffs q4–6 hrs. prn
• Caltrate 600mg+ D3 1 tablet daily

Question 1: What findings would you expect to be reported or seen on her chest x-ray results, given the diagnosis of pneumonia?

Question 2: Define further what type of pneumonia Ms. Jones has, HAP (hospital-acquired pneumonia) or CAP (community-acquired pneumonia)? What’s the difference/criteria?

Question 3:

• 3A) What assessment tool should be used to determine the severity of pneumonia and treatment options?
• 3B) Based on Ms. Jones’ subjective and objective findings, apply that tool and elaborate on each clinical factor for this patient.

Question 4: Ms. Jones was diagnosed with left lower lobe pneumonia. What would your treatment be for her based on her diagnosis, case scenario, and evidence-based guidelines?

Question 5: Ms. Jones has a known history of COPD. What is the gold standard for measuring airflow limitation?

Question 6: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain/cramps. Which choice below would be the best choice for a potential diagnosis for this? Explain your reasoning.

1. DVT (Deep Vein Thrombosis)
2. Intermittent Claudication
3. Cellulitis
4. Electrolyte Imbalance

Question 7: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain. What test could be ordered to further evaluate this?

Question 8: Name three (3) differentials for Ms. Jones’ initial presentation.

Question 9: What patient education would you give Ms. Jones and her daughter? What would be your follow-up instructions?

Question 10: Would amoxicillin/clavulanate plus a macrolide have been an option to treat Ms. Jones’ Pneumonia? Explain why or why not.

 

Order a Custom Nursing Assignment Here