Health Care and Life Sciences : Nursing

This is a history write up with the same format used for the pyc- 652/pyc-660 comprehensive physical health assessment. 

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Please follow all instructions provived.
Use APA7.
Please review the rubric, very important.
The instructor is very strict with assignments.
The name of the patient I cared for in clinical is G.K.
This is his information:
Course: PYC681 (2022 PYC-01HFB/DFNP01) Site: Kuin Med Interaction Level: Level 3 Race/Ethnicity: African American Gender: male Age: 47 years Adult/Child: Middle Age (31-55) Marital status: Single Primary Payment Method: Self Pay Case Type: Episodic Time: 10:37 – 11:00 BMI: 22.5 Height: 72 Weight: 166 Patient Setting Primary Care
Diagnosis (ICD10)
R002 Palpitations 
R030 Elevated blood-pressure reading, without diagnosis of hypertension     
Student Comments
CC: Heart palpitation.
Allergies: NKA
Vital Sign: 98.4, 20, 75, 139/90
Labs/Radiology: Comprehensive metabolic panel-serum or plasma, Lipid panel- serum or plasma, Vitamin D 25-Hydroxy, CBC W Auto Differential panel-Blood, Iron and TIBC, Vitamin B12, Hb A1C blood, TSH.
Last Completed physical: Note noted.
HPI:Presented with CC of heart palpitation. States that it started about a year ago after being diagnosed with covid 19 in December 2021. Patient states that occasionally, his heart races and he does not feel good. States sweating at night. Reports drinking alcohol occasionally but do not smoke. Report difficulty breathing at night. Presently undergoing a sleep study this week. Denied chest pain, headache, dizziness, fatigue, nausea. The patient requests  cardiac stress test. He did stress test in Russia about five years ago and wants to repeat it.
PMH: No significant past medical history.
Meds: Not on any meds.
Getting Started
The process of writing a detailed description of a complex patient in the complete H & P format and researching the condition, medications and treatment helps the student to think through the process of applying the NP skill set to patients with multiple, complex conditions.  In the process of writing the case study, the student should gain new insights into the clinical encounter that will assist them in evaluation and treatment of the next complex patient they see.
Upon successful completion of this assignment you will be able to:
•    Manage clients presenting for common acute and chronic illnesses using evidenced-based standards of practice.
•    Develop strategies to provide holistic healthcare with clients related to education, prevention and treatment of common acute and chronic illnesses.
•    Critique and develop the use of advanced technical skills in care of the sick client.
•    Apply evidenced-based health promotion practices for patients across the lifespan.
•    Collaborate within the inter-professional healthcare team in caring for the sick client.
•    Address ethical-legal issues relevant to client and provider systems related to caring for clients.
•    Clinical data and notes, relevant scholarly references, drug information reference
1.    Review the rubric to make sure you understand the criteria for earning your grade.
2.    Case Studies are to be based on actual patients seen within the clinical setting.
3.    The Case Study must be posted in the Workshop Three Assignment by day seven of this workshop.
Base all information on an actual patient encounter. Be sure to protect anonymity by using only initials and, if you choose to attach any laboratory data/tests, make sure all identifying information has been deleted. Choice of patient should be based on the following criteria:
1.    Patient should have at least one co-morbid condition and must be complex enough to meet all criteria. While the co-morbid conditions may previously exist, at least one new problem must be addressed except for well visits.  Try to select a patient with some complexity in the diagnostic process; you will learn more.  For example, an uncomplicated UTI in a 40 year-old woman with a comorbidity of well-controlled hypertension is not very challenging diagnostically.
2.    Patient is currently taking (or is being newly prescribed) a minimum of three medications from three different classes of medications.  Different medications must be addressed for each case study.  Discuss three medications that the client is taking with regard to:type of medication, mechanism of action, contraindications, adverse reactions/side effects, and pertinent patient education. Immunizations may be utilized as medications for well visits. Please focus on newly  prescribed medications first.
Case Study Format:
1.    Problem List with date of onset and resolution.
2.  S: Subjective information which will include: CC, HPI, PMH, current medications (and dosage), medication allergies, hospitalizations, medical problems, immunizations, screening, social history, family history, and ROS. This is a history write up with the same format used for the PYC- 652/PYC-660 comprehensive Physical Health Assessment.  Follow the chapter on documentation in your Physical Assessment textbook for a comprehensive assessment.
3.      O: Objective information will include: physical examination findings including physical measurements such as TPR and BP.  They physical exam should be a comprehensive exam, except that the  breast and genital exams may be omitted if not indicated.  Objective also includes pertinent laboratory data/tests. Follow the chapter on documentation in your Physical Assessment textbook for a comprehensive assessment.
4.      A: Assessment (Problems): List a minimum of three (3) differential diagnoses for each new problem addressed.  Choose one for the final diagnosis for each new problem with indications for your choice. Although the patient may have several pre-existing diagnoses, the problem being addressed at this visit must be a new one.
For example, the patient may already have a diagnosis of HTN, CAD and DM Type 2.  His complaints for this visit may be SOB and fatigue.  So, you would pick 3 differentials for SOB and fatigue. What differentials might be indicated?  Perhaps a thyroid disorder, anemia or CHF.  What work-up will help determine if a new diagnosis is indicated or if the symptoms are excerbations of the existing problems?
Differentials for pre-existing problems are not necessary. While a differential diagnosis is not required for chronic conditions, chronic conditions that affect treatment or increase the risks of the new diagnosis should be listed in the diagnosis list.  In the example above, if the patient has new onset CHF,  the patient’s HTN, CAD, and Diabetes are relevant to risk and treatment.  In addition to listing the condition, how well the condition is under control should be stated (e.g. HTN, in poor control; Type II DM in fair control). Pharmaceutical discussion:  discuss at least three of the patient’s medications.  Individualize the discussion to the patient.  See details in the grading rubric.
5.    Pharmaceutical discussion:  discuss at least three of the patient’s medications.  Individualize the discussion to the patient.  See details in the grading rubric.
6.    P: Plan: Discuss a plan for the new problem(s) listed. The new problem identified must be addressed in detail with citations from a minimum of two references.  Please write out the plan for the new problem, making sure that you have addressed diagnostic, educational, and therapeutic interventions. Also, include follow-up plans.  It is not necessary to have a separate diagnosis and plan for every comorbidity. 
7.    At least one paragraph discussion about a new diagnosis made during the visit, or a set of risk factors for a preventive visit.
8.    Reference Page:  A reference page must be included with each case study.  A minimum of two references relating to the plan of treatment as well as a reference for the medication discussion must be included, for a minimum of three references.
9.    Submit your case study to the Assignment: 3.7 Case Study Assignment by day seven of the workshop.

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