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Posted: August 21st, 2024
S.
Chief Complaint (CC):
Athscl heart disease of native coronary artery w/o ang pctrs
HPI:
The patient is a 79-year old black female who comes to the clinic complaining of discomfort in the chest. The patient states that the problem is not new but has worsened in the last week. The condition is affecting the ability to engage in strenuous activities. She denies heart attacks or bleeding. She is currently taking several medications, including a LisinoprilHCTZ 20/12.5mg 1 tab QD By mouth (PO) and Esomeprazole 40 mg 1 tab QD By mouth (PO). The medicines help lower the blood pressure of the patient. She rates the chest pain as 8/10.
Current Medications:
LisinoprilHCTZ 20/12.5mg 1 tab QD By mouth (PO)
Esomeprazole 40 mg 1 tab QD By mouth (PO)
Carvedilol 6.25 mg 1 tab 2 times a day
AM/PM by mouth (PO) Actos 15 mg tab 1 everyday PO
MPAP 325MG 1 tab TID PO daily 1 tab /3 times daily AM/NOON/PM by mouth (PO)
Vitamin D3 1000IU 1 Capsule daily PO 1 capsule daily by mouth (PO)
Magnesium 250 mg 1 tab daily PO 1 tab daily by mouth (PO)
Hydroxyzine HCL 10mg PRN Anxiety PO as needed for Anxiety by mouth (PO)
Alprazolam 0.25MG 1 tab BID PO 1 tab 2 times daily AM/PM by mouth (PO)
Calcium D 600MG 1 tab BID PO 1 tab 2 times daily AM/PM by mouth (PO)
Allergies:
NKDA
PMHx:
Hypertension
Type 2 diabetes mellitus with diabetic neuropathy, unsp
PSHx:
No information is available
Soc Hx:
No information is available.
Fam Hx:
No information is available.
ROS:
GENERAL:
The patient complains of chest pressure and pain. The blood pressure is high after experiencing a traumatic event. The patient is uncomfortable to sit and respond to questions.
HEENT:
Eyes: The patient has tearing eyes. The acuity is 20/50 OU, 20/40 OD, 20/50 OS. She complains of tearing and a burning sensation in the left eye. Ears: No information is available.
Nose: No information is available.
Throat: No information is available.
SKIN:
No bruises or lesions.
CARDIOVASCULAR:
Patient complains of chest pain and edema
She was diagnosed with high blood pressure 10 years ago. The condition has been controlled effectively using drugs and no significant medical issues.
RESPIRATORY:
No respiratory conditions noted.
GASTROINTESTINAL:
No abnormal bowel movement, nausea, and vomiting.
GENITOURINARY:
No complains of dysuria, polyuria or abnormalities in passing urine.
NEUROLOGICAL:
No abnormal bladder control, dizziness, seizures, or headache.
MUSCULOSKELETAL:
No abnormalities or pain in the back or joints.
HEMATOLOGIC:
No blood disorder.
LYMPHATICS:
No significant issue of swollen nodes.
PSYCHIATRIC:
No issues with mental functioning. No suicidal thoughts.
ENDOCRINOLOGIC:
No sweating or fever at night.
ALLERGIES:
NKDA
O.
V.S:
98.2 134/84 5’6 128lb
Physical exam:
A physical examination demonstrates the patient is sweating and uncomfortable during the examination.
HEENT, CV, Respiratory, Musculoskeletal, Lymphatic, Allergies, and Diagnostic results:
Head: No bruises or abnormal movement.
Ears: No abnormalities.
Eyes: Tearing eyes.
Nose: No running eyes.
Throat: No tonsillitis.
Neck: No swelling.
Cardiovascular: Hypertensive.
Respiratory: No abnormal lung problems or adventitious sound.
Neurological: Alert and oriented to time and place.
Diagnostic Results:
Urinalysis and electrocardiogram.
Patient Information: 79 year old black female.
Chief Complaint (CC): Athscl heart disease of native coronary artery w/o ang pctrs
HPI: The patient is a 79-year old black female who comes to the clinic complaining of discomfort in the chest. The patient states that the problem is not new but has worsened in the last week. The condition is affecting the ability to engage in strenuous activities. She denies heart attacks or bleeding. She is currently taking several medications, including a LisinoprilHCTZ 20/12.5mg 1 tab QD By mouth (PO) and Esomeprazole 40 mg 1 tab QD By mouth (PO). The medicines help lower the blood pressure of the patient. She rates the chest pain as 8/10. Monitoring the patient’s response to the current medication regimen and potential interactions is crucial for ensuring safe and effective treatment. Understanding the patient’s medical history and any underlying conditions will help guide the next steps in the assessment and treatment plan.
Current Medications: LisinoprilHCTZ 20/12.5mg 1 tab QD By mouth (PO) Esomeprazole 40 mg 1 tab QD By mouth (PO) Carvedilol 6.25 mg 1 tab 2 times a day AM/PM by mouth (PO) Actos 15 mg tab 1 everyday PO MPAP 325MG 1 tab TID PO daily 1 tab /3 times daily AM/NOON/PM by mouth (PO) Vitamin D3 1000IU 1 Capsule daily PO 1 capsule daily by mouth (PO) Magnesium 250 mg 1 tab daily PO 1 tab daily by mouth (PO) Hydroxyzine HCL 10mg PRN Anxiety PO as needed for Anxiety by mouth (PO) Alprazolam 0.25MG 1 tab BID PO 1 tab 2 times daily AM/PM by mouth (PO) Calcium D 600MG 1 tab BID PO 1 tab 2 times daily AM/PM by mouth (PO)
Allergies: NKDA
PMHx: Hypertension Type 2 diabetes mellitus with diabetic neuropathy, unsp
Hypertension: Hypertension (HT or HTN) or high blood pressure is a long-term condition that elevates the blood pressure in the arteries. Hypertension records blood pressure above 140/90. If the pressure is above 180/120, it is considered severe (Shah & Stafford, 2017). The condition can lead to health issues such as stroke or heart failure if it is not treated. Patients with hypertension should take meals with less salt, exercise, and take medication to maintain considerably lower blood pressure (Shah & Stafford, 2017). Patients with hypertension include severe headache, nose bleeding, vision problems, and chest pain. Extreme conditions lead to blood in the urine. Effective management of hypertension requires a comprehensive approach, including lifestyle modifications, regular monitoring, and appropriate medication. Healthcare professionals play a crucial role in educating patients on the importance of proactive self-care to maintain optimal blood pressure levels. Uncontrolled hypertension can have devastating consequences, making it essential for patients to work closely with their healthcare team to develop an individualized treatment plan that addresses the underlying causes and comorbidities.
Myocardial Infarction: Myocardial infarction is a heart attack that happens when the blood pressure decreases, and blood settles in some part of the heart. The immediate impact is the damage to the heart muscle (Jacovic et al., 2016). It causes various symptoms, including chest pain and discomfort. It causes fatigue, lightheadedness, and anxiety. Women are more at risk of myocardial infarction than men. Early recognition and prompt medical intervention are critical in managing myocardial infarction, as timely treatment can significantly improve patient outcomes and minimize long-term complications. Healthcare providers should be vigilant in identifying risk factors and educating patients on the importance of seeking immediate care for any concerning cardiac symptoms. Timely diagnosis and appropriate treatment are essential for reducing the risk of complications and improving long-term prognosis in patients with myocardial infarction. Regular monitoring and follow-up care are crucial to ensure the patient’s condition is stabilized and any new or worsening symptoms are promptly addressed.
Heart Failure: Heart failure or congestive heart failure occurs when the heart fails to pump sufficient blood to the body parts. Some of the causes include narrowed heart muscles or high blood pressure. The effects cause the heart to become weak or stiff to pump sufficient blood (Jacovic et al., 2016). Symptoms include shortness of breath, fatigue, and rapid heartbeat. The symptoms can resemble other heart issues, including blood pressure or myocardial infarction (Jacovic et al., 2016). Patients require a diagnostic assessment to determine the specific condition they are suffering from. Effective management of heart failure involves a multifaceted approach, including medication, lifestyle modifications, and close monitoring by healthcare professionals. Educating patients on self-care strategies and the importance of adherence to the treatment plan is essential for optimizing outcomes. Comprehensive care and patient engagement are crucial for managing the complex and evolving nature of heart failure. Regular follow-up visits and adjustments to the care plan are necessary to ensure the patient’s symptoms are well-managed and their quality of life is improved.
The assessment shows that additional information is necessary to determine the patient’s health condition. Detailed medical information is essential in guaranteeing an evaluation, medication, and treatment plan. The patient should provide information about the current medical condition to determine if the status is improving or deteriorating. She should continue taking the medication and come back for an evaluation after one week. Hypertension or high blood pressure is a condition that can rise depending on the experiences of an individual (Nerenberg et al., 2018). For instance, traumatic events can trigger a spike in blood pressure. I learned various lessons that patients require an assessment to ensure that the multiple medications they are taking are not affecting their health status. Patient education is another essential element of treatment. Patients should learn how to adjust their lifestyles to undermine their health status (Nerenberg et al., 2018). Self-care guidelines are effective in reducing the level of blood pressure. Comprehensive patient evaluation, tailored treatment plans, and ongoing patient education are crucial for effectively managing complex health conditions. Regularly monitoring the patient’s progress and making adjustments to the care plan as needed can help ensure the best possible outcomes. Collaborating with the patient to address any barriers to adherence or lifestyle changes can enhance the effectiveness of the overall treatment strategy.
References:
Bludorn, J., & Railey, K. (2024). Hypertension guidelines and interventions. Primary Care: Clinics in Office Practice, 51(1), 41-52.
Hughes, L. (2023). Moral Panic, Backlash, and the Noxious Effects of Transphobia: Assessing the Structural Drivers of Trans Health (Doctoral dissertation).
Karunarathna, I., Kusumarathna, K., Jayathilaka, P., & Withanage, C. (2024). Comprehensive Management of Hypertension: Strategies, Guidelines, and Emerging Therapies. Uva Clinical Lab. Retrieved from Comprehensive Management of Hypertension: Strategies, Guidelines, and Emerging Therapies.
Jacovic, S., Zivkovic-Radojevic, M., & Petrovic, D. (2016). Secondary hypertension: Differential diagnosis and basic principles of treatment. Serbian Journal of Experimental and Clinical Research, 17(4), 349-356. Nerenberg, K. A., Zarnke, K. B., Leung, A. A., Dasgupta, K., Butalia, S., McBrien, K., … & Lamarre-Cliche, M. (2018). Hypertension Canada’s 2018 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children. Canadian Journal of Cardiology, 34(5), 506-525. Shah, S. J., & Stafford, R. S. (2017). Current trends of hypertension treatment in the United States. American Journal of Hypertension, 30(10), 1008-1014.Macumber, I., & South, A. M. (2023). Hypertension: epidemiology, evaluation, and blood pressure monitoring. In Pediatric Kidney Disease (pp. 1283-1316). Cham: Springer International Publishing.
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Assessing, Diagnosing, and Treating Abdominal, Urological, and Gynecological Disorders
Paper instructions:
Accurate history taking of abdominal, urological, and gynecological complaints is essential for completing an assessment of the older adult. For this Assignment, as you examine this week’s patient case study, consider how you might evaluate and treat older adult patients who present with health concerns related to the abdominal, urological, or gynecological systems.
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 formatting.
79 year old black female
Athscl heart disease of native coronary artery w/o ang pctrs
CM Other Diagnosis
Bilateral primary osteoarthritis of knee
Radiculopathy, lumbosacral region
Essential (primary) hypertension
Gastro-esophageal reflux disease with esophagitis
Type 2 diabetes mellitus with diabetic neuropathy, unsp
Medication Orders
LisinoprilHCTZ20/12.5 mg 1 tab QD By mouth (PO) C
ESOMEPRAZOLE 40 MG 1 TAB QD By mouth (PO)
CARVEDILOL 6.25MG 1 TAB 2 TIMES A DAY
AM/PM By mouth (PO) Actos 15 mg tab 1 everyday po
MPAP 325MG 1 TAB TID PO DAILY 1 TAB /3 TIMES DAILY AM/NOON/PM By mouth (PO)
VITAMIN D3 1000IU 1 CAPSULE DAILY PO 1 CAPSULE DAILY By mouth (PO)
MAGNESIUM 250MG 1 TAB DAILY PO 1 TAB DAILY By mouth (PO)
HYDROXYZINE HCL 10MG PRN ANXIETY PO AS NEEDED FOR ANXIETY By mouth (PO)
ALPRAZOLAM 0.25MG 1 TAB BID PO 1 TAB 2 TIMES DAILY AM/PM By mouth (PO)
CALCIUM D 600MG 1 TAB BID PO 1 TAB 2 TIMES DAILY AM/PM By mouth (PO)
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