Pathophysiological Correlation of the Presentation - Case Study Example

SOAP N. H. 6/4/10 Time: 1000 Age: 91 Sex: F IVE CC: Patient complains “I feel my heart fluttering.” HPI: The patient presents with her daughter who lives with her. The daughter noted her mother rubbing her chest. She asked whether she was having chest pain. In reply, she stated she felt as if her heart was skipping some beats. She also complained of nausea but both the mother and the daughter reported no vomiting. The patient denies feeling sweaty. She also admitted of no respiratory distress. Medications: From history and records it was evident that the patient was on the following medications a. Aspirin 81mg q day (for her heart) b. Lexapro 10mg q day ( for depression) c. Omperazole 20mg q day ( for GERD) d. Crestor 5mg q day (for high cholesterol) e. Calcium + Vitamin D 1250mg twice a day (for osteoporosis) f. Lodine 400mg twice a day (for arthritis) g. Lumigan eye drops daily at bedtime (for glaucoma) h. Cosopt twice a day (For glaucoma). PMH: Her past medical history included a. Hypertension b. Diabetes c. Dyslipidemia with high cholesterol d. Arthritis e. Depression f. GERD g. History of breast cancer h. Glaucoma i. History or anemia. Allergies: The patient reported that she is allergic to Glucophage, ACE Inhibitors, and Celebrex Medication Intolerances: She is intolerant to Glucophage (GI sx) Chronic Illnesses/Major traumas : HTN, Diabetes Hospitalizations/Surgeries: She had been hospitalized earlier for major surgeries a. Left hip replacement b. Cholestectomy c. Hysterectomy d. Left mastectomy Family History Mother positive for breast cancer Daughter positive for DM, HTN. Father unknown. Social History Widow, who lives with daughter. The patient is a nonsmoker. The patient does not drink. ROS General Patient denies any weakness, fatigue, fever, chills, or night sweats. Cardiovascular Patient denies any chest pain, orthopnea, edema, or PND Skin Patient denies any rashes, itching or lesions. Respiratory Patient denies any shortness of breath, but does have a cough with yellow sputum. Eyes Patient has glaucoma, retinal issues with poor vision. Gastrointestinal Patient denies any nausea, vomiting, diarrhea, or abdominal pain. Ears Patient very HOH, but does not have hearing aids. Genitourinary/Gynecological Patient denies and dysuria, frequency, urgency, or hematuria. Nose/Mouth/Throat Patient denies any sore throat, epistaxis, post-nasal drip. Musculoskeletal Patient denies any swelling or weakness. Patient does have joint pain. Breast Deferred Neurological Patient denies any headaches or syncope. Patient did have an episode yesterday where room was spinning. This episode lasted for about 30 minutes, but resolved on its own. Heme/Lymph/Endo Patient has a history of hemolytic anemia for years without any treatment. Psychiatric Patient denies any anxiety. Patient has a positive history of depression on treatment. Objective Weight 147 BMI Temp 97 BP 155/78 Height 5’ 2” Pulse 78 Resp 18 General Appearance This is a 91-year-old African-American female sitting on the examination table, in no acute distress Skin Skin is warm and dry, not lesions or rashes noted. HEENT Head is atraumatic, normocephalic. Eyes: pupils PEERLA, EOM’s intact. Ears TM’s intact pearly gray. Nares are clear. No exudates. Neck trachea midline, no JVD, no lymphadenopathy. Throat clear, mucus membranes pink and moist. Cardiovascular Normal RRR, no murmurs or gallops noted. Respiratory Lungs are clear to auscultation bilaterally. Her respirations are even and nonlabored. No wheezes are audible in any segment of the chest. Gastrointestinal Her abdomen is soft. There is mild tenderness noted in the epigastric region on deep palpation. There is no hepatomegaly or no splenomegaly. There are positive bowel sounds auscultated in all four quadrants of the abdomen. Breast Deferred Genitourinary Bladder non-distended Musculoskeletal Steady gait. No edema or tenderness noted. Neurological The patient is alert and orient x 3. She answers all questions appropriately. Psychiatric Patient is pleasant and has normal mood. The patient appears well groomed. Lab Tests CBC, CMP, A1C pending Special Tests EKG done in office, EKG revealed NSR Outpatient Echocardiogram ordered due to history and age. FINAL ASSESSMENT FINDINGS AND PLAN Assessment: Patient to have outpatient echocardiogram done. Will follow up with results Patient to monitor blood pressure twice a week and keep track Call office in 1 month with readings Patient to check blood sugar twice a day. Once results are back, we will determine if blood pressure medication needs to be started. Daughter and patient instructed to return or go to nearest ER if symptoms persist. Assessment Differential Diagnosis Anxiety Palpitations Hypertension Discussion on Pathophysiological Correlation of the Presentation The presentation with a sense of skipped heart beats immediately points to cardiac arrhythmia. However, in this elderly patient such arrhythmia should be investigated appropriately. The Electrocardiogram revealed normal sinus rhythm, and the physical examination revealed regular heart beats and normal blood pressure. Thus it is also unlikely that this sensation of fluttering was due to cardiac pathology. An echocardiogram appears to be the best investigation for this purpose; however, it is also unlikely that this would demonstrate any feature of atrial fibrillation, since the patient is apparently symptomless at the present time with no respiratory distress. The absence of sweating rules out myocardial ischemia, which has further been supported by the normal electrocardiogram (Loveridge, 2004). Therefore, it can be concluded that the patient might have had an episode of brief hypertension due to anxiety which manifested itself as palpitation. Further investigation and watchful observation is necessary to arrive at a definitive diagnosis, which is commonly the case in such patients. Rationale of the Management Plan It is highly likely that the patient had had a bout of anxiety during the episode of her “fluttering sensation” which led to a temporary rise of blood pressure. The patient being elderly with past history hypertension and present history of diabetes and depression, this could be the case as well. The symptom of nausea supports this. However, her pulse rate and blood pressure antagonize this at the current point in time. While her CBC, CMP, and HBA1C are awaited, and they may indicate her blood sugar and status of the myocardium, the echocardiography would rule out any left ventricular hypertrophy that might have resulted due to her long-lasting hypertension. Thus on clinical parameters alone, it is fair to err on the side of episodic hypertension, which may ultimately be detected in the followup examinations. Until that time, the assessment about her illness do not lead to an invariable need for an antihypertensive, and a future decision can be taken if the records of her blood pressure readings are available at her one-month visit or before if a high blood pressure is detected (Alves et al., 2003). Integration of the Personal Practice Framework The very fact that the patient will follow up with the results indicated that the Orem’s theory had been used as a personal practice framework. The self-care components include awareness about the patient’s problems and possible implications to her presentation. This is indicated by the need for the patient to be aware of her diabetes for which she and her family would monitor the blood sugar and seek care if the blood sugars are abnormal. Given her history of hypertension and her being on no current antihypertensive treatment, there is also a need for regular monitoring of blood pressure and take appropriate action against a raised blood pressure. Finally all these data need to be recorded and presented at followup, so the healthcare professional can also take an appropriate care decision about her. All these indicate self-care deficits that need to be improved by the active involvement of the patient and the family in the care process, where most of the care steps are manage by themselves (Timmins and Horan, 2007). Integration of Family Theory In this care event, the family theory has been appropriately integrated. The family history has been adequately elaborated. The patient’s current illness has relationship with her family. She had breast cancer, which her mother too had. It seems the hypertension and diabetes also run in the family since her daughter had identical illness. This SOAP elicits that she lives with her daughter who herself is also suffering from illnesses. This indicates that this SOAP effectively assessed the family constellation of these illnesses. The client is frail and elderly, and she lives with her daughter. She is a widow, and thus within the family system, there was a chance that the presenting complaint might have had some links within the family relationship. Thus care given may influence the family’s stage of development. There was no apparent family crisis, but for an elderly woman like her, her illness may actually affect the family system. This history does not elaborate these factors in detail, but much of the success of current care plan will eventually depend upon the ability of the daughter to become flexible and amenable to the care plan provided mush of which would base on her daughter’s willingness to conform to the self-care strategies (St John and Flowers, 2009). Cost Analysis This care plan is possibly very cost-effective. Although in the care scenario certain tests have been done, they are absolutely essential to rule out the life-threatening nature of the illness. These are minimum investigations to rule out any problem that would need further care. While this wait for these reports are very justified, the care plan based on the assessment is barely minimal while at the same time offers provisions for the client to maintain health status and for the care provider to intervene if need arises. All these items in the care plan are virtually cost free and can be implemented at home or in the community. The cost of visit and the tests would be about $300, but the benefits are immense for the reasons explained above. There are no medications that are needed now, and the patient would be paid by her insurance. Ethical Considerations This care was ethically sound in that the patient’s autonomy has been maintained in care. At the same time the data available does not reveal the identity of the patient, and confidentiality has been maintained throughout. The care also is evidence based since without the diagnosis, apart from maintenance and monitoring, no medications have been prescribed Evaluation of Care and Documentation In this SOAP note, it is clear that I have documented all the details appropriately, and it can also be stated that the assessment is accurate. The care plan as documented is also appropriate since without further investigation and reports, it should be unwise to intervene with any medications. The echocardiography and the blood reports will establish the diagnosis, and as I await these reports, adequate treatment should be assurance and advice to watch the blood pressure. If hypertension from the blood pressure monitoring is detected, the appropriate course would be to start her on an antihypertensive drug, but for a patient of this age, starting with a low dose would be ideal. Reference Alves, LM, Nogueira, MS, Veiga, EV, de Godoy, S, and Carnio, EC (2003). White coat hypertension and nursing care. Can J Cardiovasc Nurs; 13(3): 29-34. Dunphy, L.M., (2007). Primary Care: The art and science of advanced practice nursing (2nd). Philadelphia: F.A. Davis Loveridge, N., (2004). Nursing diagnostics and electrocardiogram interpretation in relation to thrombolysis. Emerg Nurse; 12(5): 27-34. St John, W and Flowers, K (2009). Working with families: from theory to clinical nursing practice. Collegian; 16(3): 131-8. Timmins, F and Horan, P (2007). A critical analysis of the potential contribution of Orems (2001) self-care deficit nursing theory to contemporary coronary care nursing practice. Eur J Cardiovasc Nurs; 6(1): 32-9. Read More