NR 601 Week 2 Part 2 SOAP -Dyspnea Case

NR 601 Week 2 Part 2 SOAP -Dyspnea Case

NR 601 Week 2 Part 2 SOAP -Dyspnea Case

Week 2 Part 2

Patient Information:

Initials: B.J.

Age: age 70 year old

Sex: Female

Race: Caucasian

Insurance: Unknown

 

S:

 

CC: Dyspnea upon exertion

HPI:

Onset: 1 year (after the dead of her husband)

Location: generalized

Duration: 1 year to present

Characteristics: fatigue, short of breath, and insomnia

Aggravating Factors: Generalized fatigue, her feet burns and tingling, coughing, swollen feet, and cannot see well especially at night

Relieving Factors: none reported

Treatment: none reported

 

NR 601 Week 2 Part 2 SOAP -Dyspnea Case

Current Medications:

Coreg 6.25 mg PO BID

Colace 100 mg PO BID

Glucotrol XL 10 mg PO daily

Lantus insulin 20 units at HS

K-dur 20 mEq PO QD

Furosemide 40 mg PO QD

L-Thyroxine 112 mcg PO QD

 

Allergies:

Amoxicillin

 

Immunization:

She receives an annual flu shot. Last flu shot was this year

Has never had a Pneumovax

Has not had a Td in over 20 years

Has not had the herpes zoster vaccine

 

Other:

Has not seen a dentist in over 15 years, the time she got her dentures

Last colorectal screening was 11 years ago

Last mammogram was 5 years ago

Has never had a DEXA/Bone Density Test

Last dilated eye exam was 4 years ago

Labs from last year’s visit: Hgb. 12.2, Hct. 37%, Hgb. A1C 8.2%, K+ 4.2,

Na+140, Cholesterol 186, Triglycerides 188, HDL 37, LDL 98, TSH 3.7,

ALT/AST WNL.

 

PMH: 

Chronic back pain

Hypertension

Previous history of MI in 2010

 

Surgery Hx:

2010-Left Anterior Descending (LAD) cardiac stent placement

 

Soc. Hx:  She graduated from high school, and thought about college, but got married right away and then had kids a short time later. Her two sons and their wives live with her, take her to church and to the local senior center; they do all the cleaning, run errands, and do grocery shopping.

 

Fam. Hx: Both parents are deceased. Father died of a heart attack; mother died of natural causes. She had one brother who died of a heart attack 20 years ago at the age of 52.

 

ROS: Dyspnea upon exertion

Eyes: poor vision at night

PYCH: feeling depression (feeling blue)

 

NR 601 Week 2 Part 2 SOAP -Dyspnea Case

Objective:

 

Vital Signs: Ht:  5’2   Wt: 163 lbs.; BMI: 29.8   BP: 110/70    T: 98.0 po     P: 100 regular    R: 22, non-labored; Urinalysis: Protein 2+, Glucose: 4+

 

HEENT: normocephalic, symmetric. Bilateral cataracts; PERRLA, EOMI; Upper and lower dentures in place a fitting well. No tinnitus

 

NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. Thyroid non-palpable

 

LUNGS: Decreased breath sounds in bases bilaterally with rales, expiratory wheezing with prolonged expiratory phase noted throughout all lung fields. No costovertebral angle tenderness (CVAT) noted. Increase in AP diameter noted.

 

HEART: Irregularly irregular rhythm; Unable to detect S3 or murmur

 

ABDOMEN: Normal contour; active bowel sounds all four quadrants; no palpable masses.

 

PV: Pulses are 2+ in upper extremities and 1+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally;

 

NEUROLOGIC: Achilles reflexes are hypoactive bilaterally. Vibratory perception to the 128 Hz tuning fork placed at the MTP of her great toe is absent bilaterally; she is unable to discern monofilament placement in 3 locations on her left foot and 2 places on her right foot.

 

GENITOURINARY: no CVA tenderness; not examined

 

MUSCULOSKELETAL: Heberden’s nodes at the DIP joints of all fingers and crepitus of the bilateral knees on flexion and extension with tenderness to palpation medially at both knees. Kyphosis, Gait slow, but steady.

 

PSYCH: normal affect; her Mini-Cog Score is 3. Her PHQ-9 score is 22.

 

SKIN: Sparse hair noted on lower legs and feet bilaterally with dry skin on her ankles and feet

 

NR 601 Week 2 Part 2 SOAP -Dyspnea Case

Assessment: 

1. Dyspnea(ICD9-786) upon exertion r/t Congestive Heart Failure (ICD9- 428.0), Patient present with shortness of breath on exertion, swelling in the legs, ankles, feet, rales, coughing and fatigue. Sleeps with 3 pillows to prop   head up at night (Paroxysmal nocturnal dyspnea) to help with breathing (MayoClinic, 2013).

 

2. Diabetics Peripheral Neuropathy (ICD 9-250.60), diabetic patients often have tingling and burning in their feet. This is one of the symptoms of uncontrolled diabetes which leads to peripheral neuropathy (Dunphy, 2011).

 

3. Peripheral Arterial Disease (ICD 9- 443.9), patient presents with sparse hair noted on lower extremities and feet bilaterally, thready pedal pulses bilaterally (Dunphy, 2011).

 

4. Depression(ICD 9-296.22), presents with sign and symptoms of fatigue, lack of energy, insomnia, lack of motivation to perform ADLs, and lack of everyday interest in activity that was once enjoyable (Kupfer, Frank, & Phillips, 2012).

 

5. Diabetics with Ophthalmic manifestations (ICD 9-250.5), Pt states she cannot see well especially at night.

 

6. Ortho arthritis (ICD9-715.00), patient present with Heberden’s nodes at the DIP joints of all fingers and crepitus of the bilaterally knees on flexion and extension with tenderness to palpation medially at both knees.

 

Plan:

EKG (STAT)

Echocardiogram- diagnosis test to confirm a diagnosis of heart failure, EF % can be estimated, helps to visualize different etiologies of heart failure & diseases of the pericardium, myocardium, and heart valves (Dunphy, 2011).

Bone Density Test- helps to detect bone loss, in general it’s a marker which provide information about bone formation (Dunphy, 2011).

CBC, UA, Serum Creatinine, Serum Albumin, TSH, and BNP- These labs help to assist in the diagnosis. For example a BNP is a cardiac marker, CBC can show severe anemia associated with high output heart failure (Dunphy, 2011).

Daily weight (Keep a record) – Helps to evaluate if the patient is putting on fluid weight which can cause fluid overload (Dunphy, 2011).

Monitor electrolytes for hyperkalemia – Maybe secondary to renal failure as a result of heart failure, especially if ACE inhibitors have been used (Dunphy, 2011).

 

Rx: Intentionally Omitted in the preview 

     

NR 601 Week 2 Part 2 SOAP -Dyspnea Case

Patient Education:

Encourage to stop intake of salt in diet.

Teach /educate on the side effects and benefits of Zoloft, Spironolactone, Gabapentin, and Lisinopril.

Smoking Cessation teaching

Avoidance of alcohol and wine

Exercise as tolerated (Do not over exert).

Instruct to elevate legs and feet throughout the day and night to prevent or decrease swelling to legs and feet.

Avoid stress and stressful events.

Avoid herbal and complementary medicines maybe contraindicated

Notify patient of results of bone density test when available. Explain all options available and develop a treatment plan with patient.

Encourage the importance of compliance with treatment regimen and patient education.

 

Health Promotion:

Wear seat belt when in vehicle

Install smoke and carbon monoxide detector in the home

Too maintain a healthy weight and exercise daily

Monthly breast exams

Yearly health checks

Eye & Dental exams as required

 

Follow-up:

Referral to Cardiologist with results if abnormal (EKG & Echo).

Referral to Nutritionist (help with diabetic food choices)

Referral to Ophthalmologist for vision loss

Follow up Appointment in One month

Follow up with patient about smoking cessation on return visit

Follow up in one month with patient to see if her mood has gotten better. If not, will refer to Psych for additional treatment.

Patient advised to seek emergency care(ED) is experiencing increased dyspnea without relief, pain that is not relieved, temp above 101.0, thoughts of harm to others or to self or any other concerns.

 

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NR 601 Week 2 Part 2 SOAP -Dyspnea Case

References

Dunphy, L. M., Winland-Brown, J. E. Porter, B. O., & Thomas, D. J. (2011). Primary Care: The art and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F.F. Davis.

Heart.org (2012). Congestive Heart Failure. Retrieved from .http://www.heart.org/HEARTORG/Conditions/CongenitalHeartDefects/TheImpactofCongenitalHeartDefects/Congestive-Heart-Failure_UCM_307111_Article.jsp

Kupfer, D.J., Frank, E., & Philips, M. L. (2012). Major depressive disorder: New clinical, neurobiological, and treatment perspectives. Lancet, 379(9820), 1045-1055. Doi: 10.1016/S0140-673(11)60602-8

Pisano, M. (2014). Diabetic Peripheral Neuropathy. US Pharm, 39(7), 35-38. Retrieved from. http://www.uspharmacist.com/content/c/49434/