Responses to classmates must consist of at least 350 words (not including the greeting and the references), do NOT repeat the same thing your classmate is saying, try to add something of value like a resource, educational information to give to patients, possible bad outcomes associated with the medicines discussed in the case, try to include a sample case you’ve seen at work and discuss how you feel about how that case was handled. Try to use supportive information such as current Tx guidelines, current research related to the treatment, anything that will enhance learning in the online classroom.
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A 49-year-old African American woman is seen in a primary care clinic for complaints of chronic fatigue. She is post-menopausal based on self-report. In the last year, since the end of her periods, she has experienced daily hot flushes and sleep problems. She denies any other health problems. On a usual workday she drinks two cups of hot tea in the morning and one can of diet cola in the late afternoon. Currently she is taking Diphenhydramine for sleep. Her partner, who accompanied her, states that her snoring has gotten worse and it is interfering with her sleep. Subjective data: complaint of hot flashes and nighttime sweating, daytime tiredness and fatigue, has trouble getting to sleep and staying asleep. Objective data: laboratory evaluations within normal limits, Overweight 20% over ideal body weight for height, B/P 155/92. This Client has an increase risk of developing, type 2 DM, Hypertension, cardiac disorders, metabolic syndrome. A complete history should be obtained including family and personal history. The following laboratory investigations should be done complete blood count (CBC) to rule out blood dyscrasias, complete metabolic profile (CMP) to evaluate renal and liver function. Additionally, polysomnography studies should be done to assess for sleep apnea. Provide information on weight control, promote balance diet and encourage regular exercise and self-monitoring of blood pressure (Lewis et al, 2014, p 111). This patient is postmenopausal this will be an ideal time to include a clinical breast exam, pelvic exam and obtain a cervical pap smear as well.
Scenario of focused visit
A 40-year old male immigrant from Vietnam has a 1yr history of epigastric distress. Increasingly it is not relieved by over the counter antacids and Cimetidine (Tagamet).
Subjective data: reports increasing substernal pain, especially 2 to 3 hrs., after eating, avoids alcohol, takes over the counter antacids. Smoked 1 pack cigarette per day for 20 years stopped 2 years ago. Increasing fatigue with exercise, Occasional black bowel movements. Takes Chinese medicine for frequent back pain. This client requires a focused assessment of the gastrointestinal (GI) system to include inspection, auscultation, palpation and percussion. Points to be included in the history include how often are meals consumed and identify what foods are aggravating. It will be important to evaluate nutritional status. Determine weight and other anthropometric measures. Also ask about the number of bowel movements per day and the color and consistency of stools. Has the patient had any episodes of nausea and vomiting. Have you noticed blood in the vomitus? What is the color of the vomitus if any? Objective data: Height 5ft 5 inches, Weight 140 1bs, B/p 124/78, pulse 76, resp 18 br/min, temperature 98.4 F, oxygen sat 98%. Diagnostic studies to be undertaken CBC, CMP, endoscopy and biopsy. Endoscopy revealed a duodenal ulcer and biopsy revealed Helicobacter pylori infection. Since this patient smoked for many years an assessment of the respiratory system can also be completed after initial assessment of the GI system (Lewis et al, 2014, p 959).
Reference
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher. L., (2014) Medical-surgical nursing: Assessment and management of clinical problems (10th ed.). St. Louis, MO: Elsevier
Mosby.
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