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Nursing High School - Case Study Example

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Summary
Mr. S, is a 73 y/o widower, whose c/c is swelling in bilat. LE & a weight gain of 26 pounds in a "short period of time". Pt also complains of occasional SOB relieved by rest. Pt feels that he "actually is in pretty good health because of all of the time spent outdoors"
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Nursing High School Case Study
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Focused Scenario Running head: FOCUSED SCENARIO "Focused Scenario" In APA Style Focused Scenario 2 Mr. S, isa 73 y/o widower, whose c/c is swelling in bilat. LE & a weight gain of 26 pounds in a "short period of time". Pt also complains of occasional SOB relieved by rest. Pt feels that he "actually is in pretty good health because of all of the time spent outdoors"
Family Hx> Pt's father died of CVD at age 54 and pt's mother died of breast CA at age 65. Pt's grandfather died of hypertension at age 97. Pt lives with his 47 y/o daughter, 54 y/o son-in-law and 26 y/o twin grandsons in his 145 acre farm.
Social Hx> Pt drinks 2-3 beers in the evening p dinner. Pt's food intake is from organic food produced from the animals and fruits & vegetables on his farm.
Occupational Hx> Pt works by helping the 6 farmhands and his family in managing the farm for the past 52 years.
This scenario lacks very important information which should be gathered during the health history/interview process. As for this patient, or for any patient for that matter, it is vital that the past medical history of the patient should be asked as to the diagnosis, date of onset, duration and medical management. The chief complaint was present, however, it still lacked in some aspects such as the onset of the complaint, duration and precipitating and relieving factors (though in this scenario, one relieving factor was given for the SOB). Lloyd & Craig (2007) noted that the medication history of the patient is "crucially important" and should not only consider the current medications but include as well past medications. For this patient, history of smoking or for any smokers in the household should be asked because of his cardiovascular risk.
Focused Scenario 3
For physical examinations, important body systems which should be checked should include the cardiovascular system, respiratory system and the muscular system, particularly the lower extremity muscle and joints. The cardiovascular system should be checked because of the presence of the lower extremity swelling (dependent edema), sudden weight gain and breathlessness. The respiratory system should also be checked because of the complaint of SOB. The specific examination findings from the scenario should be documented on the objective part of the SOAP notes. Findings which are similar or coherent can be placed under the same category. Those that were observed in the patient should be placed under the ocular inspection, any tenderness or nodules are under palpation, cardiovascular and respiratory assessment can be placed under cardiorespiratory assessment and the measurement of swelling can be placed under anthropometric measurements. Assessment tools that can be utilized are stethoscope for the auscultation of cardiorespiratory assessment, tape measure for the anthropometric measurements, and spirometer for the lung volume assessment. My clinical reasoning/ inferences based on the scenario include heart failure because of the c/c of swelling in bilat. LE, weight gain in a short period of time and occasional SOB which fit some of the signs and symptoms of heart failure and also because of the strong family history of cardiac diseases. Cor pulmonale (R-sided heart failure with concomitant respiratory affectation is also a differential diagnosis in particular because of the respiratory symptoms. Damaged valves in the veins of the lower extremities can cause lower extremity swelling. This can also be a parasitic cause because of the nature of the patient's work which increases its risk for parasitic infection.
Focused Scenario 4
References
Lloyd H, & Craig S. (2007). A guide to taking a patient's history. Nursing Standard (Royal College of Nursing (Great Britain) : 1987). 22 (13), 5-11. Read More
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