coursework-banner

Complete an academic clinical history and physical note based on a patient seen during clinical/practicum.

 

History and Physical Note

 

Chief Complaint or Reason for Consult: “Shortness of breath.”

History of Present Illness (HPI): M.K. is a 79-year-old AA female who presented with a complaint of shortness of breath. The SOB began about four days ago when she started feeling a need to catch her breath, and this worsened when she was walking or doing her normal house chores. The patient also reported an increased breathing rate, and her body was unusually hot. However, the dyspnea with exertion rapidly progressed to severe dyspnea at rest, accompanied by a high respiratory rate. On arrival at the ED, the patient was anxious and agitated. She was immediately administered a high concentration of inspired oxygen.

Past Medical History: History of COPD, diagnosed at 63 years. Admitted thrice in the past two years due to pneumonia.

Past Surgical History: Appendectomy at 43 years.

Family History: The mother had heart failure and died from a heart attack at 89. The father died from pancreatic cancer at 86 years. The elder sister died from a heart attack at 78 years.

Social History: M.K. is a retired Travels consultant. She lives with her husband in their farmhouse in Kerrville, TX. They have three children, 55, 53, and 46 years old. She has had a smoking history since she was 22 years old and stopped at 64 years following a COPD diagnosis. She

smoked 2 PPD before her being advised to quit. She admits to taking 3-4 glasses of whiskey on weekends. Her source of income includes her pension and interests from various investments. She has no advanced directives.

Allergies: No food/drug allergies.

Home Medications: Ipratropium inhaler 2 actuation every 6 hours; Salmeterol 1 inhalation BD; Vitamin D/Calcium supplements.

Hospital Medications: Low-molecular-weight heparin, IV Hydrocortisone 200 mg OD.

Review of Systems:

  • CONSTITUTIONAL: Positive for fever, activity intolerance, and increased fatigue
  • EYES: Denies eye pain, excessive tearing, or blurry vision.
  • EARS, NOSE, and THROAT: No ear pain, ear discharge, hearing loss, nasal discharge, sneezing, or sore throat.
  • CARDIOVASCULAR: Positive for dyspnea on exertion and at rest. Denies palpitations, chest discomfort, or edema.
  • RESPIRATORY: Reports increased breathing rate. Denies cough, sputum, or wheezing.
  • GASTROINTESTINAL: Denies nausea, vomiting, abdominal pain, bowel changes, or tarry stools.
  • GENITOURINARY: Denies dysuria, blood in urine, abnormal PV discharge, or pelvic pain.
  • MUSCULOSKELETAL: Denies joint pain or stiffness, back pain, or muscle pain
  • INTEGUMENTARY: Denies skin rashes, discoloration, bruises, or lesions.

    Complete an academic clinical history and physical note based on a patient seen during clinical practicum

  • NEUROLOGICAL: No headaches, dizziness, muscle weakness, loss of consciousness, or tingling sensations.
  • PSYCHIATRIC: Reports occasional sleep disturbance with nighttime awakening. Denies anxiety or mood symptoms.
  • ENDOCRINE: Denies increased urination, excessive hunger, acute thirst, or heat/cold intolerance.
  • HEMATOLOGIC/LYMPHATIC: Denies easy bruising, bleeding, or swollen lymph nodes.
  • ALLERGIC/IMMUNOLOGIC: Denies rashes, hives, or any allergic reactions.

Physical Exam:

  • GENERAL APPEARANCE: AA female patient in her late 70s. She is well-nourished and in acute respiratory distress. She is alert and oriented.
  • VITAL SIGNS: BP- 110/70; HR-128;RR-26; Temp- 100.7; SPO2- 88; HT; 5’2; WT- 132; BMI- 24.1
  • HEENT: Normocephalic and atraumatic. Eyes: Sclera is white; Conjunctiva is pink; PERRLA. Ears: Tympanic membranes are patent, transparent, and shiny. Nose: No rhinorrhea or epistaxis. Patent nostrils and nasal septum; Mouth: Pink and moist mucous membranes; Tongue is mid-line, pink, and non-inflamed; One tooth cavity. Throat: Tonsillar glands are non-erythematous.
  • NECK: Full ROM; Trachea is mid-line; Thyroid gland is normal.
  • CHEST: Asymmetrical chest expansion. Labored breathing with the use of accessory muscles.
  • LUNGS: Faint heart sounds. Dullness to percussion. Rales present. No wheezing or rhonchi.
  • HEART: Heart rate- 128 b/min. No edema or jugular veins distension; S1 and S2 normal on auscultation. No gallop sounds, bruits, or systole was heard.
  • BREASTS: Symmetrical; No skin color changes, nipple discharge, breast tenderness, masses, or lumps.
  • ABDOMEN: Round with normal pigmentation and moves up and down on respiration. No bruits; BS normoactive on all quadrants. No hepatomegaly or splenomegaly on percussion. No tenderness, masses, guarding, or organomegaly.
  • GENITOURINARY: [Female]. Normal external genitalia No pelvic tenderness. Normal urethral meatus is normal.
  • RECTAL: Normal sphincter tone. No masses or tenderness.
  • EXTREMITIES: Cyanosis present in fingers.
  • NEUROLOGIC: The patient is restless, anxious, and confused.
  • PSYCHIATRIC: Alert and oriented x4. Affect is appropriate. Coherent speech and thought process. No delusions, hallucinations, obsessions, homicidal, or suicidal thoughts were noted.
  • SKIN: Dark, warm, and well-perfused skin with good turgor. Bluish discoloration in the extremities.
  • LYMPHATICS: Lymph nodes are non-palpable.

Laboratory and Radiology Results:

  • ABG: PaO2-54 mmHg; PaCO2-38 mmHg
  • WBC- 12,500 µL
  • FEV1 -to-FVC ratio- decreased

Differential Diagnosis:

Respiratory Failure with SIRS: Type 1 respiratory failure is characterized by a partial pressure of oxygen (PaO2) < 60 mmHg and a normal or decreased partial pressure of carbon dioxide (PaCO2). Patients present with respiratory symptoms like dyspnea, cough, sputum production, chest pain, hemoptysis, and wheezing. Symptoms from other organ systems like fever, decreased appetite, heartburn, and significant weight loss are also present. The diagnostic criteria for Systemic Inflammatory Response Syndrome include at least two of the following criteria: fever >38.0°C or hypothermia <36.0°C, tachypnea >20 breaths/minute, tachycardia >90 beats/minute or leucocytosis >12,000/µL (Rababa et al., 2022). The patient has a reduced PaO2 of 54 mmHg with a PaCO2 within a normal range, which indicates respiratory failure. She also has respiratory symptoms and has met the criteria for SIRS with tachycardia, tachypnea, fever, and elevated WBC count of 12,500 µL.

Acute respiratory distress syndrome (ARDS): ARDS is non-cardiogenic pulmonary edema presenting rapidly progressive dyspnea, tachypnea, and hypoxemia. Other clinical manifestations include pleuritic chest pain, sputum production, fever, and rales (Kaku et al., 2020). This is a differential diagnosis based on the patient’s positive symptoms of dyspnea, tachypnea, fever, rales, and a low PaO2, indicating hypoxemia.

Community-Acquired Pneumonia (CAP): The characteristic pulmonary physical exam findings include: Tachypnea, rales over the affected lobe, increased tactile fremitus, bronchial breath sounds, and dullness on chest percussion (Rider & Frazee, 2018). The patent presents with pulmonary symptoms characteristic of CAP, including tachypnea, rales, and dullness on percussion. She also has a fever, reduced saturation levels, and elevated WBC, which occur in CAP.

Treatment Plan: Treatment will aim to correct hypoxemia since it is a threat to organ function.

Medications: Low-molecular-weight heparin

IV Hydrocortisone 200 mg OD

Salmeterol 1 inhalation BD

Non-pharmacologic: Oxygen supplementation via nasal cannula to correct hypoxemia (Summers et al., 2022).

Health Education: Adherence to pharmacological therapy. Pulmonary rehabilitation interventions for COPD.

Consultations: Consult a Pulmonary specialist if the respiratory failure does not improve with treatment.

Follow-up: The patient will be scheduled for a follow-up two weeks after discharge.

Geriatric or Ethical Considerations:

Geriatric patients are predisposed to Respiratory failure. The clinician should consider the factors that trigger Respiratory failure in geriatrics, like acute exacerbations of COPD, acute heart decompensation, severe community-acquired pneumonia, and pulmonary embolism. The patient, in this case, has COPD, which is the likely cause of respiratory failure. Foccillo (2019) explains that in the management of respiratory failure in geriatrics, it is mandatory to reverse and prevent tissue hypoxia through conventional oxygen therapy or invasive or non-invasive mechanical ventilation. Ethical considerations surround the principles of beneficence and nonmaleficence. The clinician should uphold the two ethical principles by implementing interventions that will promote the best treatment outcomes and cause no harm to the patient. Thus, interventions should be guided by evidence-based research. In addition, the clinician should obtain consent from the patient and respect her treatment decisions.

 

 

 

References

Foccillo, G. (2019). The Infections Causing Acute Respiratory Failure in Elderly Patients. Ventilatory Support and Oxygen Therapy in Elder, Palliative and End-of-Life Care Patients, pp. 35–45. https://doi.org/10.1007/978-3-030-26664-6_5

Kaku, S., Nguyen, C. D., Htet, N. N., Tutera, D., Barr, J., Paintal, H. S., & Kuschner, W. G. (2020). Acute respiratory distress syndrome: etiology, pathogenesis, and summary on management. Journal of Intensive Care Medicine, 35(8), 723-737. https://doi.org/10.1177/08850666198550

Rababa, M., Bani Hamad, D., & Hayajneh, A. A. (2022). Sepsis assessment and management in critically Ill adults: A systematic review. PloS one, 17(7), e0270711. https://doi.org/10.1371/journal.pone.0270711

Rider, A. C., & Frazee, B. W. (2018). Community-Acquired Pneumonia. Emergency medicine clinics of North America, 36(4), 665–683. https://doi.org/10.1016/j.emc.2018.07.001

Summers, C., Todd, R. S., Vercruysse, G. A., & Moore, F. A. (2022). Acute Respiratory Failure. Perioperative Medicine, 576–586. https://doi.org/10.1016/B978-0-323-56724-4.00039-3

 

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS; Complete an academic clinical history and physical note based on a patient seen during clinical/practicum.

Lopes Write Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.

Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.

Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?

Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.

Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.

If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.

I do not accept assignments that are two or more weeks late unless we have worked out an extension.

As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.

Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

Important information for writing discussion questions and participation

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

  • Your response needs to be a minimum of 150 words (not including your list of references)
  • There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
  • Include in-text citations in your response
  • Do not include quotes—instead summarize and paraphrase the information
  • Follow APA-7th edition
  • Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

  • A minimum of 6 responses per week, on at least 3 days of the week.
  • Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
  • Each response needs to be at least 75 words in length (does not include your list of references)
  • Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
  • Follow APA 7th edition
  • Points will be deducted if the above is not followed
  • Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
  • Here are some helpful links
  • Student paper example
  • Citing Sources
  • The Writing Center is a great resource