Nursing

Based on this patient case, and using the focused SOAP note as a reference, develop a case study presentation that includes the history of present illness (HPI), appropriate positive and negative physical exam findings, past medical and surgical history, diagnostic results, diagnosis including differentials that were ruled out, and treatment plan.

NEED
1. objective
2.assessement
3. Planning
4. Differential dx
5. reflection
6. three possible discussion questions/prompts for your classmates to respond to, and at least five scholarly resources to support your diagnostic reasoning and treatment plan.

ANSWER

 

Focused SOAP Note

Patient Information:

CY, 44, Female, Race

S

CC: “fever”

HPI: 44 years old female admitted to sub-acute rehab for rehabilitation.  Diagnosis of perforated colon, s/p Hartmann’s procedure and appendectomy. Fever started 4 days ago after admission from the hospital. No labs done since admission, also she was admitted with wound to her mid abdomen with scant amount of drainage. Shes been taking Tylenol 325 mg tab every 6 hours when her fever will go down, highest temp was 102.

Current Medications:

Ascorbic acid 500mg tablet by mouth daily

Depakote 250mg capsule by mouth BID

Ferrous Sulfate 325mg tablet by mouth BID

Sevelamer carbonate packet 2.4 gm by mouth TID

Sucralfate 1 gm tablet BID give before breakfast and dinner

Allergies:

NKA

PMHx:

Anemia

Bipolar

Acute kidney injury

Sepsis

Obesity

Up to date on all immunizations. Received last COVID vaccine January 2021

Social and Substance Hx: Single, lives with her mother, currently unemployed,

Nonsmoker, smokes marijuana user last used 2/2021 drinks occasionally.

Fam Hx:

Father: DM, hyperlipidemia, passed away 5 years ago. Mother DM

Surgical Hx:

Mental Hx:

Pt is currently in advanced stage of dementia. Hx of depression. Mood has been stable; occasional bouts of agitation.

Violence Hx:

No history regarding violence, no current issues.

Reproductive Hx:

Post-menopausal.

ROS:

Constitutional: denies fever, chills, fatigue, malaise, or weight loss

Eyes: Denies any recent changes in visual acuity, dry eyes or eye pain.

ENT: Denies ear pain, discharge, tinnitus, or hearing loss. Denies nasal obstruction, discharge, bleeds, sore throat, hoarseness, or dysphagia.

Skin: Denies rashes, itching, ulcers/growths, bleeding, increased bruising, dryness, or suspicious lesions.

Cardiovascular: Denies chest pain, palpitations, syncope, DOE, orthopnea, PND, peripheral edema. Pt reports a sustained increase in blood pressure.

Pulmonary: Pt denies any Sob or increased Sob with exertion or during the night

Endocrine: Denies temperature intolerance, polydipsia, polyuria, polyphagia, weight loss or weight gain

Genitourinary: Denies dysuria, nocturia, hematuria, urinary hesitancy or frequency Gastrointestinal: Reports epigastric “burning” intermittently. Pt reports that this is relieved with medication. Denies nausea, vomiting, bloating, constipation, diarrhea, or pain with defecation. Denies any blood noted in stool or changes in bowel habits.

Musculoskeletal: Reports history of chronic back pain that causes sciatica flairs. Denies joint swelling, muscle cramps, muscle weakness or stiffness.

Neurologic: Denies transient paralysis, weakness, paresthesias, seizures, syncope, tremors, vertigo

Psychological: Patient denies feeling depressed or suicidal.

Hematological/Lymphatic: Denies abnormal bruising, bleeding, enlarged lymph nodes

O

Physical exam:

VS: Temp: 99 F; P 99, Regular; BP: 129/89 Left arm; RR: 20 ; Ht 5’ 4”, 188 lbs

General: Pt is oriented to person, place, situation and time, No distress.

Skin: mid abdominal wound measuring 5×5 cm dehisnece with scant amount of serous drainage.

Cardiovascular: S1 and S2 sounds present, no murmur, rub or gallop

Respiratory: Normal breath sounds bilaterally, no adventitious sounds.

Soft + tenderness, non-distended, hypo BS left lower colostomy

GU: no foley

Extremities: no edema

Lymphatic: Lymph nodes not palpable or tender.

O (objective)

The clients ‘ temperature was high from the physical exams undertaken, where her Bp was BP: 129/89. The patient never portrayed any signs of distress. Her skin had a scant amount serious amount of severe drainage, and her breathing was normal with no adventitious sounds.  The patient also Soft + tenderness, non-distended, hypo BS left lower colostomy. She had no edema, where her Lymph nodes not palpable or tender.

Diagnostic results:

A (Assessment)

There is, therefore, a need to analyze the condition that the patient is likely suffering from.  This to offer her the timeliest diagnosis and treatment for what she may be suffering from.

Differential diagnoses:

A first likely diagnosis is based on the fact that the patient has perforated bowel. This could be due to an infection which could lead to sepsis if not well treated. Sepsis and Spector shock can result from an infection in an internal organ in the body and hence needs to be given a significant focus on treatment (Sespis Alliance, 2021).  s/p Hartmann’s procedure had been performed on the patient, which entails opening the colon’s end. There is hence a likelihood that the colon could have an infection. (Dr. Jasmine Shaikh, 2020) The process could have been undertaken to prevent the infection from spreading to the body’s healthy parts.

Another likely diagnosis for the patient is a problem associated with the appendectomy, where there may be possible problems resulting from the past operation. Such a problem is associated with bleeding, wound infection, blocked bowels, and injury to nearby organs (The Johns Hopkins University, 2021).  It could also have resulted in illness, redness, and swelling, some of the patient’s symptoms. Other likely infections can be diagnosed for the patient. To establish why she has high a fever may include a viral or bacterial infection, inflammation, or the least likely tumor.

P (Plan)

From the patient’s diagnosis, further analysis is needed. First, there will be a need to analyze the type of medication she has been taking to understand their effects and examine whether they are helping her with her current condition.  There will also be a need to monitor her mental health condition, considering that she has previously been diagnosed with Bipolar dementia and depression. She also has a history of hyperlipidemia with her father, who was assessed on. This will help understand whether the patient will need to undergo therapy or any medication related to her condition.

Based on her past medical history, there is also a need for testing her kidney since she previously had an acute kidney injury. The test will seek to understand whether she has a kidney failure or any issue reeled to her kidney.  This will be through taking urine tests, blood tests, and also measuring her urine output (National Kidney Foundation Inc., 2021). In the case the test turns out positive, there will be a need for the patient to be transferred to a specialist who will help with dealing with such a condition, since it could be serious and pose a major harm to this patient’s wellbeing.

Patient counseling is very vital for this particular patient. This is since it may help her cope with how she feels and share all the information, including her recent habits and what she probably feels she could be ailing from.  Through counseling, she will also be made feel at ease and collaborate with the caregivers to ensure that she completely recovers from whatever condition or infection she may be suffering from (Patel, et al., 2018).  The counseling will also help smoothen recovery for the patient and help in the future diagnosis of what she may be ailing from.

Differential dx

The diagnosis shows that the patient is likely to suffer from several conditions, which are causing the symptoms. The first possible condition is sepsis, which is life threatening complication of an infection. It could eb due to chemicals released in the bloodstream with an aim of fighting an infection that triggers inflammation in the body  (Sespis Alliance, 2021). A second possible condition is abdominal abbess.  This entails a pocket of pus, or collection t of infected fluid /. It can be anywhere within the abdominal cavity and also around organs in the abdomen such as kidneys, liver and pancreas, which is threatening to the patient. It is also likely that the patient is suffering from wound infection, which could be causing the bleeding, hence the pain and the fever. Testing the three possible conditions will guide medical evaluation and treatment and help with the patient’s recovery.

Reflection

From this case study, I explore the likely complications faced by the patient. It manifests that she has an underlying issue that should be thoroughly analyzed before concluding what she is suffering. While the case study describes more about the patient, I try to share some ideas that can be used in the future for patients with similar conditions.  I also try to broaden her issues to ensure that no problem is left untouched in her diagnosis. Mental wellness is also a significant issue related to patient wellbeing and is also incorporated in the discussion to ensure that the patient is stable throughout the process. Through past medical studies on similar patients, I can reflect on the patient’s condition and provide my best solution to what she is ailing from.  I hope that the patient will have a quick recovery and soon return to normal life after establishing sustainable solutions to her problem.

Possible questions for other classmates to respond to

1. What are your thoughts about my process of diagnosing the patient and the symptom analysis of this particular condition?
2. What are your suggestions on the treatment plan that would be most suitable for this particular case?

iii.  How differently would you approach this particular case in terms of diagnosing and understanding what this patient is ailing from?

 

 

References

Dr. Jasmine Shaikh, M. (2020). Why Is Hartmann’s Procedure Necessary? Retrieved from https://www.medicinenet.com/why_is_hartmanns_procedure_necessary/article.htm

National Kidney Foundation Inc. (2021). Acute Kidney Injury (AKI). Retrieved from https://www.kidney.org/atoz/content/AcuteKidneyInjury#:~:text=Acute%20kidney%20injury%20(AKI)%2C,of%20fluid%20in%20your%20body.

Patel, A., Bakina, D., Kirk, J., von Lutcken, S., Donnelly, T., Stone, W., & Turkoz, H. (2018). Patient counseling materials: The effect of patient health literacy on the comprehension of printed prescription drug information. . Research in Social and Administrative Pharmacy, 14(9), 851-862.

Sespis Alliance. (2021). perforated bowel. Retrieved from https://www.sepsis.org/sepsisand/perforated-bowel/#:~:text=If%20the%20perforation%20occurs%20in,infection%20can%20lead%20to%20sepsis.

The Johns Hopkins University. (2021). Treatment, tests, and therapies. Appendectomy. Retrieved from https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/appendectomy#:~:text=Some%20possible%20complications%20of%20an,appendix%20bursts%20during%20surgery%20(peritonitis)