PATIENT INITIALS:  Mrs. P.       AGE: 55            SEX: FEMALE    RACE: WHITE

CC:  The patient came to the hospital for consultation regarding her hypothyroidism.

HISTORY OF PRESENT ILLNESS: This is a 55-year-old female with a history of I-131-induced hypothyroidism years ago who presents with increased weight and edema over the last few weeks with a 25-pound weight gain. She also has a diagnosis of fibromyalgia, inflammatory bowel disease, Crohn’s disease, COPD, and thyroid disorder as well as disc disease.  She's found increased abdominal girth and increased edema in her legs.  She has been in hypertension for years on Norvasc and lisinopril. She has intermittent sweats that have no noticeable improvement in her bowel condition.  She takes away her Synthroid hormone from her.  She's been on generic for the last couple of months and in the past has had problems with that. 

MEDICATIONS: Levothyroxine 300 mcg daily, albuterol, Asacol, and Prilosec. Her amlodipine and lisinopril are on hold.
ALLERGIES:  None.
PAST MEDICAL HISTORY: Inflammatory bowel disease with Crohn, hypertension, fibromyalgia, COPD
PAST SURGICAL HISTORY: Hysterectomy and a cholecystectomy.
SOCIAL HISTORY:  No smoking or drinking
FAMILY HISTORY: Positive for thyroid disease
REVIEW OF SYSTEMS: Positive for fatigue, sweats, and weight gain of 20 pounds. PHYSICAL EXAMINATION:
GENERAL: She is an obese female.
VITAL SIGNS: Blood pressure 140/70 and heart rate 84. She is afebrile.
HEENT: Extraocular movements were intact. There was moist oral mucosa.
NECK: Supple. Thyroid gland atrophic and nontender.
CHEST: good
CARDIOVASCULAR: Regular 

ABDOMEN: Benign.
EXTREMITIES: Showed 1+ edema.
NEUROLOGIC: She was awake and alert.
LABORATORY DATA: TSH 0.28, free T4 1.34, total T4 12.4 and glucose 105.
IMPRESSION/PLAN: This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism.  Hypothyroidism with the disorder Graves several years earlier is similar to radioactive iodine. 

She is a euthyroid clinically and biochemically. 

Her TSH is slightly suppressed, but her free T4 is fine, 

and I will not decrease her levothyroxine dose with her weight gain. 

I'm going to stay 

On Synthroid 300 mcg daily. 

If she wants to lose more weight, in six weeks ' time I 

Would perform the thyroid function test to ensure she also isn't hyperactive thyroid. 

 

 

1. IRON DEFICIENCY ANEMIA

PATIENT INITIALS:  T.Q       AGE: 55            SEX: MALE    RACE: WHITE

CC:  Patient came in with iron deficiency anemia and had blood in his stool.

HISTORY OF PRESENT ILLNESS: Patient is a 55-year-old gentleman. He developed deficiency anemia and he had blood in his stool. Anemia was diagnosed months ago when he presented with unusual pruritus and he got a CBC. At that time he was discovered to have haemoglobin of 9 and MCV 65.
PAST MEDICAL HISTORY: Chronic diarrhoea, Chronic obstructive pulmonary disease.
MEDICATIONS: Iron supplement.
ALLERGIES: None.
FAMILY HISTORY: Coronary artery disease, hypertension.  Non history of colon cancer or any type of other cancer.
SOCIAL HISTORY: Patient smokes 1-1/2 packs for more than 40 years. 6 beers per day and no drug history.
REVIEW OF SYSTEMS: No night sweats. Good appetite. Stable weight. No chills, no fevers. No visual problems. No hearing problems. Chronic diarrhoea for more than 3 years. His stool is daily, 1-2 times per day and very loose with dark and bright blood in the stool on and off for more than 5 months. Respiratory review of systems was significant for COPD. Patient not on oxygen and his COPD is mild. Denies any neurological problems, psychiatric problems, endocrine problems, haematological problems, lymphatic problems, immunological problems, allergy problems.

PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 221 pounds. Height 6 feet 1 inch. Blood pressure 124/62, heart rate 87, and temperature 98.4, saturation 98%. Pain is 0/10.
GENERAL: Good attention to grooming.
HEENT: PERRLA. EOM intact. Oropharynx is clear of lesions. Good dentition.
NECK: Supple.
LUNGS: Clear to auscultation No wheezing and crackles. 

CARDIOVASCULAR: Regular rate and rhythm...
ABDOMEN: No masses, no tenderness. No distention. 

RECTAL: Good sphincter tone. No palpable nodules. No masses. No blood. Dark stool, the patient is taking iron.
BACK: No costovertebral tenderness bilaterally.
LYMPHATICS: None.
MUSCULOSKELETAL: Good, stable gait. No clubbing, no cyanosis, no pitting edema. Full range of motion. No joint deformities.
SKIN: Clear of rashes and lesions.
NEUROLOGICAL: Cranial nerves II-XII within normal limits. Deep tendon reflexes 2+ in both knees and both biceps. No local weakness.
PSYCHIATRIC: Good judgment and insight.
ASSESSMENT & PLAN: Patient needs evaluation for source of bleeding with a colonoscopy. The patient will need antibiotic prophylaxis prior to procedure because of valvular abnormality and we are not completely aware of what type of abnormality. PSA was in the normal range. The patient had x-ray which showed pulmonary hyperinflation and emphysema. The patient will be followed up with result of colonoscopy.

 

Self-Assessment Form

Summary of strengths:

Opportunities for growth:

Now, write 3–4 possible goals and objectives for this practicum experience. Ensure that they follow the SMART Strategy, as described in the Learning Resources. 

References

Jacob, A., Tarachand, J., & R, R. (2015). Health assessment. Clinical Nursing Procedures: The Art of Nursing Practice, 1-1. https://doi.org/10.5005/jp/books/12418_2

Misto, K. (2017). Family perceptions of family nursing in a magnet institution during acute hospitalizations of older adult patients. Clinical Nursing Research, 28(5), 548-566. https://doi.org/10.1177/1054773817748400

Nursing education: Review of assessment, clinical care, and implications for practice regarding older adult patients with cancer. (2018). Clinical Journal of Oncology Nursing. https://doi.org/10.1188/18.cjon.s2.19-25

 

Genital Assessment

Introduction

As a nursing practitioner, one is bound to be faced with different number of cases that will call for more examination and evidence based practice.  The following analysis is based on the evaluation of the patient genitalia and the influence it carries on the clinical conclusion regard a patient with complicated data.  This analysis report will thus look at the patient objective and subjective information that is introduced in the SOAP note and come up with additional information which will be incorporated in the medical report.  There will also be use of various evidence based literature that provides analytical tests support in the assessments. There will also be analysis of the patient subjective information that will be documented. As a nursing practitioner, analysis should be done with clinical support on the importance of making a particular diagnosis.  The paper will also provide three conclusions regarding the patient diagnosis.

Subjective Data Analysis

This section provides an analysis of the patient subjective information for regarding the current situation.  Based on the subjective data the patient’s chief complaint was having bumps on my bottom that I need to have looked at”. According to the history of Present Illness, the patient is a 21 year old female undergraduate student that comes to the clinical reporting as having outer bumps in her genital area (Denniston, 2014).  According to the patient, the bumps are not painful however they are rough. Also, from the assessment the patient reports that she is sexually active with multiple partners in the previous year.  The first sexual contact happened when the patient was 18 years. Also, the patient does not have any form of vaginal discharge.  Her major concern is the extent to which the bumps have been there, when she only saw them seven days ago.  The patient also reports that she had her last pap smear three years ago where it turned out negative for dysplasia. The patient also reported that she was once diagnosed with Chlamydia two years ago, she however finished the prescription. The patient also reports having asthma. The medications she has been prescribed for the condition was Symbicort 160.4.5 mg, she has no know allergies (Crouch et al., 2010).  According to family history, the patient denies history of cervical or breast cancer from family members.  The father however has history of GERD and HTN. Based on her social history, the patient does not smoke nor use any form of illicit drug.  Occasionally the patent uses alcohol when she is with friends.

It was very important to understand the subjective information of the patient as this helps in creating a clinical portfolio. Also, the information regarding the patient medical history and family history helps in deciding on a proper conclusion.  It was also important to find out whether she was keeping up with all her vaccination, whether she had been screened for Pap smear and the results as these are some factors that could lead to Human papilloma virus infections if not checked (Liesegang, 2017).  Also, by coming to understand the one she has been seeing as a healthcare provided especially for gynecological visits would be very helpful to assemble.  The patient also reported being sexually active; this means that it would also be important to find out from her who among her sexual partners was positive for STDs and whether she was tested for one.   Based on the date, the patient informed that she was diagnosed with Chlamydia, however, she did not have any other form of STDs. The reason it was important to ask the patient regarding her sexual activity was that it would mean she would have to call for her partners to come and be tested as well. Question about her immunization history was very important since people that do not follow through to immunization often become very vulnerable to infections, and could be at risk of antibodies that are used in the prevention of STDs.

Objective data Analysis

It was also important to assess the patient objective data from the visit.  Based on the objective data her vital signs were not so bad where her temperature stood at 98.6, Blood pressure at 120/86, RR 16, HT 5’10’’ and WT 169lbs.  Her heart was RRR with no murmurs, the lungs CT with an asymmetrical chest wall.  Also while analyzing her genitals, there was a normal female hair pattern distribution, there was no swelling or masses.  The patient’s urethral meatus was intact there was no discharge or erythema. The perineum was intact except for a healed episiotomy scar.  The vaginal mucosa was moist and milk with presence of rugae.  Checking on her abdomen it produced normal active bowel sounds, it was soft, negative Murphy’s and Mc Burney. It was also important to obtain the HSV specimen.  From this analysis there was some examination missing from the objective date. Much concentration was given to the genital evaluation. Other important aspects like the mental and neurological aspects were missing. It is possible that the patient could also be suffering from anxiety due to the bumps in her bottom that might deny her a normal psychological status.  Also, it would be important to look at the head to toe and skin evaluation, including looking at the mucosa in her mouth. Due to her sexual history, it would be in line to conduct full evaluation of the skin (Douglas, 2007).  Also assessing the body in general would help in analyzing the social and biological risks.  Lastly it would also be important to conduct a pregnancy test on the patient to reduce the risk of infection to the baby in case she was pregnant.

Supporting and Rejecting the Assessment

Based on the information gathered from the assessments, it is possible that the patient could be having a chancre, due to the area of the ulcers in the patient genitalia, and the fact that the patient reported the chancre was not painful. One of the reasons I would not support the diagnosis is because there was some absent information leading to some insignificance.  There was also no outcome from demonstrative or HSV testing for infections, which calls for the need to affirm whether the patient has chancre.

Diagnostic tests

Based on the Patient’s Objective information, it is important to conduct HSV testing, especially to understand the presence of sores, it also has a great level of sensitivity. Based on the assessment, the most extreme level of vesicles can be exposed and the base of the patient ulcer can also be traced using a Dacron swab, this will provide the diagnosis with clear information (Liesegang, 2017).  These tests can be repeated after 6-12 weeks. Based on the vital signs, it is evident the patient is not suffering from any sort of fever, however it will be important to conduct a CBC to check on contamination.

Differential Diagnoses

Based on the patient information the following are different diagnoses:

Chancre

From the analysis of the SOAP it is this is the closest diagnoses because the patient was having bumps in her outer labia.  Also, chancre are usually popular with female patients that report being sexual active with different partners.  Also based on the fact that the patient reported suffering from an STD, previously, could indicate the presence of Chancre which is an indication of the initial phase of syphilis, though the wounds could be varied as those present in her labia (Van Rooijen et al., 2016). Chancres usually appear, round, firm and painless, which is exactly what the patient reported in her subjective data. In most cases chancres will last to about 6 weeks and health with treatment.  However, it can develop to STDs, especially syphilis.

Chancroid

The patient could also have a possible chancroid, however this diagnosis usually present itself as a solitary profound ulcer that is mostly painful. If this was the case, it would also mean that the patient would have a burning sensation which is not reported in a subjective data.  According to the patient, the bumps she has are painless, and she discovered having it for about 7 days. This means that the condition cannot be chancroid.

Herpes Simplex Virus

This could also qualify as a diagnosis for the patient however, based on the subjective and objective data, it is evident that the patient does not report a burning with sores, tingling and basic manifestations common with people suffering from Herpes Simplex Virus (Liesegang, 2017).  As common with any patient suffering from Herpes Labialis, they would depict a burning and tingling sensation, due to the development of a vesicular ulcerative injury which is in the perioral mucosa and oropharynx. However, from the subjective data the patient does not have vesicular sores in her mucosa and oropharynx, there is also no burning sensation or tingling.

Conclusion

The following reported provided a diagnostic analysis of a 21-year-old patient who came to the clinic reporting having bumps on her bottom. Based on the analysis 3 different diagnosis were possible for her condition, however, the closest diagnosis was Chancre based on the subjective and objective data.  

References

Crouch, N., Michala, L., Creighton, S., & Conway, G. (2010). Androgen-dependent measurements of female genitalia in women with complete androgen insensitivity syndrome. BJOG: An International Journal of Obstetrics & Gynaecology, 118(1), 84–87. https://doi.org/10.1111/j.1471-0528.2010.02778.x

Denniston, G. C. (2014). Genital autonomy: (2010th ed.). Springer.

Douglas, J. M. (2007). Making progress against stds. Skin & Allergy News, 38(2), 12. https://doi.org/10.1016/s0037-6337(07)70017-7

Inamadar, A. C. (2003). Perforating chancre: Any cause-effect relation with HIV infection? Sexually Transmitted Infections, 79(3), 262-262. https://doi.org/10.1136/sti.79.3.262

Liesegang, T. J. (2017). Herpes simplex virus ocular disease. Herpes Simplex Viruses, 239-274. https://doi.org/10.1201/9780203711828-10

Van Rooijen, M. S., Koekenbier, R. H., Hendriks, A., De Vries, H. J., Van Leeuwen, P., & Van Veen, M. G. (2016). Young low-risk heterosexual clients prefer a chlamydia home collection test to a sexually transmitted infection clinic visit in Amsterdam, The Netherlands, a cross-sectional study. Sexually Transmitted Diseases, 43(11), 710-716. https://doi.org/10.1097/olq.0000000000000517