NU 650 Week 4 Assignment 1

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Subjective

Patient name: E.N

Race/Ethnicity: American

DOB: 2/10/1995

Age: 28y

Marital Status: Not Married

Chief Complaint (CC): “Over the past three days, my wheezing and shortness of breath have gotten worse, and I believe it may be due to allergens in the zoo.”

History of Present Illness (HPI): A 28-year-old patient with a medical background of asthma has presented with a progressive worsening of wheezing and dyspnea over three days. During the summer months, she works at the local zoo to financially support her educational expenditures. The individual refers to encountering two recent episodes of asthma attacks. According to the patient’s account, she was engaged in a motor vehicle collision around two months prior, followed by a post-traumatic seizure approximately two weeks later. The cessation of seizures was observed after the initiation of anticonvulsant phenytoin therapy. The worsening of symptoms occurs when the patient is subjected to severe cold during both morning and evening periods. The symptoms are exacerbated by touching the animal’s fur in the zoo.

Review of Systems (ROS):

General: Positive for breathing difficulties, wheezing, coughing, and inability to exercise. Denies headaches, swollen extremities, or seizures.
Skin: The skin has normal pigmentation, is adequately hydrated, and lacks visible scars.
Hair/nails: The head appears normal without any observed spots. Nails have typical appearance characteristics.
HEENT: The patient exhibits PERRLA, TM without signs of inflammation, absence of oral cavity lesions, and no presence of nystagmus
Respiratory: Confirms the presence of symptoms such as positive shortness of breath, coughing, and wheezing, indicating a potential respiratory condition.
Cardiovascular: The individual does not report experiencing palpitations, pressure, or chest pain. The individual exhibits a heightened pulse rate.
Peripheral Vascular: Sensing is average—normal temperature sensitivity.
Musculoskeletal system: Opposes the existence of fractures. As the patient goes to and from the zoo, their gait is normal, and their movement is also expected.
Neuro: Cranial nerves are not damaged. Hence, speech is unimpaired. Denies changes in memory, sleep, or mood.Refutes the existence of numbness, feeling dizzy, and weakness.
Gastrointestinal: Denies having loose stool, abdominal pain, vomiting, nausea, burning sensations, and Constipation.
Urinary: Confirms the absence of nocturia, polyuria, scorching, sense of urgency, hesitancy, or striving genital information records.
LMP: Not applicable; denies sore drainage.
Hematologic: The patient denies having ever suffered from anemia. The patient reports never being injured, wounded, or receiving a blood transfusion.
Endocrine: The patient denies a history of diabetes, increased appetite, thirst, or urination.
Past Medical History (PMH):

Chronic illness: The patient experienced the onset of asthma at 20 and has since been managing the disease for two years. At age 21, she was additionally diagnosed with mild congestive heart failure (CHF). The physician implemented a dietary regimen for the patient that limited their sodium intake. Enalapril was administered to the patient to mitigate exacerbating symptoms associated with congestive heart failure (CHF).

Social History: The patient is currently unmarried and resides in the same household as her two sisters, a living arrangement that has persisted since the passing of their parents. The patient reports abstaining from the consumption of alcohol, refraining from smoking and abstaining from the use of illicit substances. The individual consumes a total of seven caffeinated beverages daily. The individual is fond of participating in low-intensity physical activities within their residence and attends a fitness facility during diminished symptoms. The individual under consideration identifies as a Christian and intermittently attends religious services at a church. The individual in question asserts a lack of adherence to religious convictions that may influence the prescribed medical intervention.

Past Surgical History: None

Family History: The father succumbed to renal disease at 60. The mother died from congestive heart failure (CHF) at 58. The patient’s siblings exhibit good health and have no documented history of childhood diseases.

Medications: The patient takes 5 milligrams of enalapril, an albuterol inhaler as needed, 300 milligrams of theophylline capsules twice daily, and 300 milligrams of phenytoin sustained-release capsules.

Immunizations: All vaccines have been thoroughly updated.

Allergies: She has no documented evidence of any allergies that she may have towards medications, foods, latex, environmental factors, or herbal therapies.

Functional Assessment: Health Maintenance Practices

Activity/exercise:Confirms engaging in mild exercise in the house and sometimes visits the gym.
Sleep/rest: On average, she sleeps more than seven hours and feels refreshed whenever she wakes up.
Nutrition/elimination:Eats healthy, No elimination.
Relationships/resources: She is not married. Has a good relationship with her siblings and friends.
Spirituality: She claims to be a Christian and attends church occasionally.
Coping and stress management:The patient says she has moderate stress regularly but does not require therapy or medicine because she can manage her anxiety.
Safety: She reports being very safe at home
Screenings: No reports for screening.

Objective

General:The individual exhibits signs of adequate physical growth, a pale complexion, and heightened anxiety levels.
Vital signs: Temp: 97, B.P.: 160/86, H.R.: 122 /min, R.R.: 21, O2: 93% RA
Height:66 inches Weight: 130 BMI: 20
Examination:
HEENT: The head is shaped typically. The head has thick hair that is evenly spaced out. Eyes: Symmetric, full EOM, PERRLA. There were no signs of tears, ocular discharge, conjunctival/scleral injection, or palpebral ptosis. Ears: Symmetric, bilateral T.M.s appear pearly grey and are free of redness, release, or wax from the ear obstruction. According to Weber and Rinne’s test results, there is no hearing loss. Healthy teeth, a midline septum, and pink mucosa in the nose and mouth. No uvula abnormalities, ulcers, glossitis, or mouth blisters. There is no oropharyngeal redness, tonsils that are enlarged or without white patches, exudate, or exudate itself. Pharynx and tonsils in the throat, usual for the fossa. Tonsils: A soft palate instead of tonsils. N.L.
Lymph Nodes: There are no nodules, goiter, torticollis, neck pain, swollen lymph nodes, or limitations on movement.
Respiratory: There are 22 breaths each minute—easy, symmetrical breathing with no cyanosis. The thorax is symmetrical, pain-free, and has good fremitus and expansion. The lungs are resonating loudly. The breath sounds vesicular, without any crackles or rhonchi. A slight wheeze could be heard during forced expiration. Wheezing cannot be stopped by causing a cough. Even though the bilateral diaphragms have shrunk by 3 cm, no unintended noises exist.
Cardiovascular:Typical sinus rhythm with standard S1 and S2.
Abdomen: No lumps or bumps; not bloated; not overly tender; smooth.
Peripheral Vascular System: The extremities are warm, symmetrical, and edema-free. Both the stasis and the varicosities remained unchanged. The knee lacks both a strong sense of pain and extreme flexibility. There were no discernible femoral or abdominal bruits. Palpation can reveal the axilla and epitrochlear lymph nodes in a healthy person.
Cranial nerves: Complete WNL from CNII to C.N. Coordination: No unneeded movements occur. The posture works. Normal steps, a solid foundation, an arm swing, and turning are all parts of gait. Many people walk on their toes. Muscle size and tone are normal. Bilateral strength in its entirety. They use 5/5 of their muscle power to flex the R/L arm against the stiffest resistance. The fingers and toes of the hands and feet feel lightly touched and pinched.
Assessment:
Chronic Obstructive Pulmonary Disease

A medical illness known as chronic obstructive pulmonary disease ( COPD) is characterized by continuous airflow restriction within the lungs (Stolz et al., 2022). Given that the patient exhibits wheezing symptoms, there is a possibility that they are suffering from the specific condition in question. The presence of a potential indication indicates this. However, the emergence of the illness might be ascribed to extended exposure to irritants, such as animal fur, inside the limits of a zoological habitat. This is because animal fur can cause an allergic reaction. As a result, there is no longer any risk of the patient contracting the disease due to the short time (two years) they have been employed (Bhurane et al., 2019).

Congestive heart failure (CHF)

This medical condition hinders the heart’s ability to pump blood effectively, resulting in compromised circulation throughout the body (Naik et al., 2021). This commonly arises from underlying conditions such as coronary artery disease, hypertension, or cardiac valve abnormalities. Symptoms such as dyspnea, fatigue, and edoema in the lower extremities may arise due to fluid accumulation in the tissues as cardiac function declines. Congestive heart failure (CHF) can be effectively managed with pharmacological interventions, modifications in lifestyle, and, in some instances, surgical interventions. The enhancement of quality of life and prognosis for individuals with congestive heart failure (CHF) is significantly influenced by timely detection and ongoing medical treatment. The individual exhibits wheezing considered one of the indicative symptoms of congestive heart failure (CHF). Additionally, the patient has a medical background of congestive heart failure (CHF). Based on the patient’s administration of medicine for congestive heart failure (CHF), it can be concluded that it is not a contributing factor (Naik et al., 2021).

Gastroesophageal reflux disease (GERD)

This is a persistent gastrointestinal condition characterized by the recurrent retrograde movement of gastric acid into the esophagus, resulting in irritation and the manifestation of symptoms such as heartburn, regurgitation, and chest discomfort. (Katzka & Kahrilas, 2020) The etiology of this illness frequently involves a compromised lower esophageal sphincter, obesity, or nutritional influences. There is evidence suggesting that gastroesophageal reflux disease (GERD) contributes to the exacerbation of asthma symptoms, including wheezing. This can be attributed to stomach acid reflux into the tracheal tract. (Khan et al., 2021)

Primary Diagnosis

The patient’s primary diagnosis is asthma, contributing to the heightened symptoms observed over the previous three days. The patient further reports an escalation in the frequency of asthma exacerbations within the recent months.

PLAN

Plan: Please confirm the diagnosis. In the event of a deterioration, seeking further consultation with a specialist in asthma and allergies is advisable.
Diagnostics: Tachycardia and nonspecific ST-T wave alterations are typical ECG findings during an asthma attack.
Labs: Chest X-ray; right and left costophrenic angles blunting
Pharmacologic intervention: Peak flow was 76 m3/min, and following albuterol administration, the FEV-FEV1/FVC was 60%, the FVC was 3.0 l, and the 1.8 l. Inhaler for albuterol as needed for coughing, two puffs every two hours.
Non-pharmacologic intervention: Encourage her to keep up her regular exercise, weight loss, avoidance of irritants, and reduction/management of emotional stress (Ramírez-Venegas & Robles, 2022).
Referrals: None
Education: Nebulizer technique instructions, reminders to rinse your mouth after taking your medication, attack alerts, and an asthma action plan are all meant to help you follow your treatment plan correctly. Furthermore, they are advised to reduce triggers and irritants because they can exacerbate symptoms.
Follow up: Come back in 2 weeks to assess the level of asthma control and make any necessary medication adjustments since the asthma is now under control.

References

Bhurane, A. A., Sharma, M., San-Tan, R., & Acharya, U. R. (2019). Efficient detection of congestive heart failure using frequency localized filter banks for the diagnosis with ECG signals. Cognitive Systems Research, pp. 55, 82–94. https://doi.org/10.1016/j.cogsys.2018.12.017

Katzka, D. A., & Kahrilas, P. J. (2020). Advances in the diagnosis and management of gastroesophageal reflux disease. BMJ, m3786. https://doi.org/10.1136/bmj.m3786

Khan, M., Singh, G. K., Abrar, S., Ganeshan, R., Morgan, K., & Harky, A. (2021). Pharmacotherapeutic agents for the management of COVID-19 patients with preexisting cardiovascular disease. Expert Opinion on Pharmacotherapy, 22(18), 2455–2474. https://doi.org/10.1080/14656566.2021.1960311

Naik, M. S., Pancholi, T. K., & Achary, R. (2021). Prediction of congestive heart failure (CHF) ECG data using machine learning. Intelligent Data Communication Technologies and Internet of Things, pp. 325–333. https://doi.org/10.1007/978-981-15-9509-7_28

Ramírez-Venegas, A., & Robles, R. E. (2022). Faculty opinions recommendation of the global, regional, and national prevalence of, and risk factors for, chronic obstructive pulmonary disease (COPD) in 2019: A systematic review and modeling analysis. Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature. https://doi.org/10.3410/f.741814534.793593237

Stolz, D., Mkorombindo, T., Schumann, D. M., Agusti, A., Ash, S. Y., Bafadhel, M., Bai, C., Chalmers, J. D., Criner, G. J., Dharmage, S. C., Franssen, F. M., Frey, U., Han, M., Hansel, N. N., Hawkins, N. M., Kalhan, R., Konigshoff, M., Ko, F. W., Parekh, T. M., … Dransfield, M. T. (2022). Towards the elimination of chronic obstructive pulmonary disease: A Lancet commission. The Lancet, 400(10356), 921-972. https://doi.org/10.1016/s0140-6736(22)01273-9

NU 650 Week 4 Assignment 1

Please carefully review and follow the SOAP grading rubric and Samples and (1-S, 2-O, 3-A and 4-P) when completing this assignment. Please write six pages with six or more scholarly sources which are not more than five years old.

Due: Thursday 11PM

Value: 100 points

Due: Day 7

Gradebook Category: Assignments: SOAPs

Overview

The goal of this assignment is to practice writing a SOAP note for a sick or episodic visit related to the focus system(s) reviewed in this week’s learning materials. Review the SOAP Note Rubric.

Instructions

Choose an abnormal finding related to the content that was covered this week. Examples from this week would include: hair loss, thickening of the nails, rash, skin lesion, fatigue, malaise, etc.

Develop a focused SOAP note for the abnormal finding. You do not need to find a patient to match this finding. The point is for you to think about what the HPI would be, what the rest of the history may look like, what the objective findings will be, the potential differential diagnoses, and the plan. In other words, you are creating the patient scenario and documenting it in SOAP format. Please be sure to include all relevant information and not just the system the abnormal finding is in.

Refer to the Grading Rubric Refer to the Grading Rubric to see how your work will be assessed.

Readings

Required

Bickley, L. (2021). Bates’ guide to physical examination and history taking (13th ed.). Lippincott, Williams, & Wilkins.

Chapter 10: Skin, Hair, and Nails
Chapter 25: Assessing Children: Infancy Through Adolescence
Chapter 26: The Pregnant Woman
Chapter 27: The Older Adult

Dains, J.E., Baumann, L.C., & Scheibel, P. (2020). Advanced health assessment and clinical diagnosis in primary care (6th ed.). Elsevier.

Chapter 28: Rashes and Skin Lesions

Bates Videos Lectures

Please view the mini-videos below to learn more about the specific components of the physical exam. We have listed each mini-video here so that students can better manage their time as well as have a quick access to revisit a specific component of the exam. However, when students enter the Bates Physical Exam website, they will be able to choose a “play all” option that allows all videos to be viewed in succession by each system.

Skin and Abdomen:

Vol 1: Head-to-Toe Assessment: Adult