Posted: December 24th, 2022
Health assessment DB wk #7 eSSAY.
Chief Complaint: the client came to the clinic with the chief compliant of shortness of breath and a productive cough with clear sputum.
HPI: The patient is a white Caucasian Male who came in with complaints of shortness of breath which had started few days ago and has gradually been worsening. The shortness of breath worsens with activity such as walking or even when lying down at night and nothing makes it better. Another associated symptom is a productive cough with a clear phlegm and persistent fatigue. The client had noticed edema of the lower extremities and the abdomen with some weight gain. He was on a fluid pill but ran out of the prescription ad made a decision not to take it anymore since he frequently visited the bathroom.Health assessment DB wk #7 eSSAY.
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Current Medications: “fluid pill” – client failed to state the name, dosage, frequency and duration that he had taken the drug
PMHx: Previously diagnosed with hypertension.
Social Hx: Previous tobacco smoker who tried to quit but failed. Currently, he smokes 3 cigarettes a day.
Family Hx: The family history was not discussed. However, it is necessary that it should have been discussed since a positive family history of CHF increases his risk of heart failure.
Review of Systems
General: No fever. Positive weight gain of 5 pounds since the last visit which was 3 months ago, patient was generally weak and fatigued.
Skin: Cool and dry
Pulmonary: Patient has dyspnea on exertion, a productive cough with clear phlegm.
Cardiovascular: the patient has orthopnea, PND and edema of abdomen and lower extremities.
Neurologic: The patient is awake, alert and oriented to person, place, and time.
Allergies: No stated or reported allergies
Vitals: Blood Pressure 162/90mmHg, Pulse 94bpm, Respiratory rate 22cycles/min and labored; Temp 97.9 F oral; O2 92% on room air; Weight 215 with 5lbs weight gain since last visit 3 months ago.
General: the patient is anxious and worried
Cardiovascular: Client has a regular heart rate is 94bm, auscultation of S1, S2, S3 revealed that they were all present and a 3 out of 6 systolic murmur was heard.
Peripheral vascular: has +3 peripheral edema that extends to the knees bilaterally, 2+ bilateral dorsalis pedis pulses were noted
Thorax and lungs: the thorax was symmetrical, with vesicular breath sounds and rales that had scattered on the entire lung fields. No wheezes or rhonchi.Health assessment DB wk #7 eSSAY.
Abdomen: was slightly distended with normoactive bowel sounds based on the auscultation of all the quadrants of the abdomen.
Skin: cool and dry
Diagnostic Testing: In order to gather more information about the patient’s condition, an EKG, Chest x-ray, and blood tests should be performed.Health assessment DB wk #7 eSSAY.
EKG- the physical exam elicited that the client has a 3 out of 6 systolic murmur although his heart rate was regular. Therefore, an EKG would help to elicit the client’s heart electrical activity and whether its straining to pump blood.
Chest X-ray-a chest-ray would be essential in evaluating the lungs, heart and chest walls in diagnosing the client’s shortness of breath and cough. More importantly, for this client, it would help to ascertain whether his heart had enlarged, whether or not the lung fields were clear and the extent of damage to the lungs due to tobacco smoking. Therefore, it would help to diagnose Heart failure and to rule out other causes of shortness of breath such as pulmonary edema and COPD.
Blood tests-blood test would help to determine whether or not the client’s immune system is fighting an infection.
1. Congestive Heart Failure-the client’s symptoms of edema, dyspnea, weight gain and recent weight gain of 5 pounds are consistent with heart failure. Heart failure occurs as a result of failure of the heart to pump adequately pump blood. The symptoms experienced by clients with heart failure include: fatigue, swollen lower limbs, rapid heartbeat and shortness of breath (Inamdar & Inamdar, 2016), which makes it a more likely diagnosis.
2. COPD: is a chronic inflammatory lung condition which causes obstruction of the flow of air from the lungs. COPD symptoms include: difficulty in breathing, mucus production, wheezing, weight loss and cough. It is occurs as a result of long term exposure to irritants, more commonly cigarrete smoke. Based on the fact that this client was a long term cigarrete smoker increases his likelihood of COPD (Berliner et al., 2016). However, his complaints of difficulty breathing when lying down at night and weight gain reduce the likelihood of this diagnosis.
3. Coronary Artery Disease: coronary artery disease occurs when major blood vessels which supply blood to the heart and its muscles become diseased or damaged. Its symptoms include: sweating, shortness of breath, chest pain, discomfort, vomiting and nausea. However, since the patient has no complaints of angina/chest pain, it is a less likely diagnosis.Health assessment DB wk #7 eSSAY.
4. Pulmonary Edema: pulmonary edema is condition where the lungs get filled with fluid making the body to struggle getting adequate oxygen which leads to shortness of breath. The symptoms of pulmonary edema include: difficulty breathing when lying supine either during the day or night, shortness of breath. sudden weight gain, swelling of the lower limbs and general body fatigue (Berliner et al., 2016). Based on the fact that the patient experienced difficulty breathing at night makes pulmonary edema a less likely diagnosis.
5. Pulmonary Hypertension – from the patient’s history and vital signs, it is undeniable that he is suffering from hypertension (BP 162/90mmHg). Patients with hypertension report of symptoms of severe headache, weight loss, chest pain, irregular heartbeat, difficulty breathing and vision problems (Maron & Galiè, 2016). However, this patient’s heartbeat was regular and had no severe headache or vision problem which makes it a less likely diagnosis.Health assessment DB wk #7 eSSAY.
Episodic/Focused SOAP Note Template
Initials, Age, Sex, Race
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.Health assessment DB wk #7 eSSAY.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.Health assessment DB wk #7 eSSAY.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.Health assessment DB wk #7 eSSAY.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.Health assessment DB wk #7 eSSAY.
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