Polypharmacy is defined as being on 5 or more medicines, and is a major concern for providers as the use of multiple medicines is common in the older population with multimorbidity, and as one or more medicines may be used to treat each condition.

• Discuss two (2) common risk factors for polypharmacy. 
• Give rationale for each identified risk factor.
• Discuss two interventions you can take as a Nurse Practitioner in your clinical practice to prevent polypharmacy and its complications.

 using  at least 3 evidenced-based

 

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TO WRITE 1 COMMENT TO EACH POST WITH 2 CREDIBLE REFERENCE ABOVE 2013.

Post 1

 

Patient Information:

XX, 15yo, Male

S.

CC: “Dull pain, both knees”

HPI:

Location: Both knees (would ask him to point to the exact location)

Onset: NA (would ask if onset was sudden or gradual, was he doing an activity when it occurred)

Character: Dull, catching, clicking

Associated signs and symptoms: NA (would ask if the pain wakes him up at night, what activities are limited due to the knee pain, can he straighten or bend the knees)

Timing: NA (would ask when the pain occurs)

Exacerbating/ relieving factors: NA (would ask what makes it worse, what makes it better)

Severity: NA (would have pain rated on a scale of 0-10)

Current Medications: NA (would ask what medication he is on if any)

Allergies: NA (would ask if any medication or food allergies)

PMHx: NA (would ask about general health, past illnesses,  past surgeries, hospitalizations, immunizations,  any blood transfusions, any psych history)

Soc Hx: NA (would ask if he works, and where, does he play sports and if so what and how often, does he smoke, does he drink alcohol, does he do any illicit drugs, does he drink caffeine, if so how much and how often for each, has he lost or gained any weight, does he follow a specific diet, and what about exercise) I would also ask if he uses sports safety equipment if he plays in sports, does he wear a seatbelt, does he ride with others that may be impaired by drugs or alcohol.

Fam Hx: NA (would ask about parents, grandparents, sibling health history and any deaths, ask about cancer, cardiac diseases, diabetes)

ROS:

GENERAL:  NA (would ask if any weight loss, fever, chills, weakness or fatigue)

HEENT: NA Eyes, Ears, Nose, Throat (would ask if any drainage, problems, blurred vision, problems swallowing etc.)

SKIN:  NA (would look for skin rashes, moles, or open wounds)

CARDIOVASCULAR:  NA (would ask about heart problems, blood pressure, swelling to lower extremities)

RESPIRATORY:  NA (would ask about shortness of breath, cough or sputum)

GASTROINTESTINAL:  NA (would ask about anorexia, nausea, vomiting or diarrhea. abdominal pain or blood)

GENITOURINARY:  NA (would ask about burning on urination, would address sexual activity/protection)

NEUROLOGICAL:  NA (would ask about headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities, changes in bowel or bladder control)

MUSCULOSKELETAL:  unilateral to bilateral knee pain, clicking, and catching under the patella, (would further ask if he had any limping at time of knee pain, any back pain, joint pain or stiffness)

HEMATOLOGIC:  NA (would ask if any anemia, bleeding or bruising)

LYMPHATICS:  NA (would ask if patient noticed any enlarged nodes or has a history of splenectomy)

PSYCHIATRIC:  NA (would ask if any history of depression or anxiety)

ENDOCRINOLOGIC:  NA (would ask if any sweating, cold or heat intolerance, polyuria or polydipsia)

ALLERGIES:  NA (would ask if history of asthma, hives, eczema or rhinitis)

O.

Physical exam: knee checks I would perform are:

1. Bulge Sign: Applying lateral pressure to the area adjacent of the patella will be positive if fluid is present on medial knee joint, also palpating this area will allow for assessment of patellar tendinitis. (Dains, Baumann, and Scheibel, 2016)
2. McMurray Maneuver: With patient supine, maximally flex knee and hip; externally and internally rotate tibia with one hand on distal end of tibia: with other hand, palpate joint to test for meniscus injury if palpable or audible click is heard. (Dains, Baumann, and Scheibel, 2016)
3. Collateral Ligament Test: Applying medial or lateral pressure with the knee flexed 30 degrees and when it is extended. If sprained it will show laxity in movement and no solid end points. (Dains, Baumann, and Scheibel, 2016)
4. Lachman Test: With knee flexed 30 degrees, pull tibia forward with one hand while other hand stabilizes femur. A positive test is a mushy or soft end feel when tibia is moved forward, indicating damage to anterior cruciate ligament. (Dains, Baumann, and Scheibel, 2016)
5. Monitor patient gait, ability to do stairs, or kneel, monitor for flexion and extension pain to look for tibial tubercle injury related to Osgood-Schlatter disease. (Dains, Baumann, and Scheibel, 2016)

Overall look of knee color, swelling, temperature of skin to palpation, and patient vitals to monitor for fever.

Diagnostic results:

Complete Blood Count to monitor white count to look for infection. Estimated sed rate to look for inflammation. (Dains, Baumann, and Scheibel, 2016)

 Radiography 4 view film of knee for an anteroposterior, lateral, tunnel, and a 30-degree sunrise view of the patella. (Dains, Baumann, and Scheibel, 2016) Radiography films would help view knee, ligaments, and bone to view for injury. May also need a knee Ultrasound. Use of magnetic resonance imaging or computed topography scan would be utilized if no answers obtained from physical exam and preliminary diagnostic tests.

A.

Differential Diagnoses:

1. Patellar Tendinitis: Jumpers knee, overuse of knee, inflammation of distal extensors of the knee joint. Excess strain on knees from jumping and running. Patient experiences dull, achy knee pain, associated with clicking or popping, can involve one or both knees. (Dains, Baumann, and Scheibel, 2016) Patellar tendinopathy is a common musculoskeletal dysfunction in athletes with 11-14% of non-elite players of basketball, volleyball, and handball per Scattone Silva, Nakagawa, Ferreira, Garcia, Santos, and Serrao (2016). They further share 53% quit sport careers due to it, as the impaired knee extensor muscles cause tendon overload and the recommendation is for strengthening of quadriceps and hamstring muscles to help distribute force equally with jumping and increasing the ankle dorsiflexion as these contribute to patellar tendinopathy
2. Meniscus Injury: A medial meniscus injury is more common than a lateral meniscus tear and is generally obtained due to twisting injuries, the patient will have problems with flexion, and bearing weight they will experience clicking and catching of the knee which can be swollen and tender. (Dains, Baumann, and Scheibel, 2016) This will generally affect one knee rather than both, especially at the same time. Mosich, Lieu, Ebramzadeh, and Beck, (2018) share 80-90% occur with athletic activity and meniscus repair seen in two studies showed a 37% mean re-tear rate within 17 months. They further share success rate reported at 80% with simple tears and arthroscopy is the surgical repair choice. They state 889% return to sports at the pre-injury level with isolated meniscus tears, and repair is better than meniscectomy due to increased risks of osteoarthritis in the long run.
3. Medial Collateral Ligament Sprain: Caused by valgus stress to the knee, the patient typically limps after the injury. Andrews, Mckean, and Ebraheim (2017) share the medial collateral ligament is one of four major ligaments that supports the knee, stabilizes the medial knee joint, protects of valgus stress, rotational forces and anterior translational forces on the tibia. They further share 40% of all knee injuries of this type are related to trauma and change in speed direction of knee activity the patient can experience the knee giving out or popping, then the joint fills with blood. They also state the patient can return to previous activity without treatment in 10-20 days, but injury is graded and if a grade 3 can recur and may require surgery as other ligaments may be involved and these recur at a rate of 23%.
4. Anterior Cruciate Ligament (ACL) Tear: Occurs if the knee is twisted or hyperextended causing stretching or tearing of ligaments, with the ACL in the center of the knee, the patient hears a pop, giving way of the knee and swelling. (Dains, Baumann, and Scheibel, 2016) The ACL is the 2nd ligamentous restraint of the knee to abduction per Bates, Nesbitt, Shearn, Myer, and Hewett (2015), the medial cruciate ligament ruptures 20-40% of the time with the ACL injury. They further share the ACL restrains 85% of the anterior force of the knee. This type of injury can take 6-12 months to heal, typically requires surgery in 75% of patients. (Bates et al., 2015) Bates et al. further shares there are negative effects within 15 years of surgery and 70% occur during non-contact sports with rapid deceleration and change in direction.
5. Osgood-Schlatter Disease: Found in adolescent males most often, patient experiences pain and swelling in the anterior part of the tibial tubercle. Strenuous activity of the quadricep muscle causes limping by the patient, and pain that worsens with kneeling or climbing stairs, the knee may be warm to touch, and tender at the tibial tubercle with increased pain on flexion and extension while having a normal knee joint. (Dains, Baumann, and Scheibel, 2016) Traction of the patellar tendon at its attachment of tibial tubercle mostly is sports related with running and jumping, the patient can use ice, non-steroidal anti-inflammatories, and exercises that strengthen the quadriceps and hamstring muscles per Indiran, and Jagannathan (2018). This is typically found in males more than females 215 are adolescent athletes compared with 4.5% non-athletes per Kalbiri, Tapley, and Tapley (2014).  They further share the injuries are related to earlier induction to sports, decreased time between sporting seasons, and performance pressure that lead to overuse. They also share patients can be tested using the single leg squat as this is difficult to do with this injury. Utilizing straight leg raises, wall squats, and rope jumping after healing can strengthen quadricep and hamstring muscles and the use of a intra patella strap can help strengthen the knee for mobility.

P.  NA

References

Bates, N. A., Nesbitt, R. J., Shearn, J. T., Myer, G. D., & Hewett, T. E. (2015). Relative strain in the anterior cruciate ligament and medial collateral ligament during simulated jump landing and sidestep cutting tasks. American Journal of Sports Medicine, 43(9), 2259-2269. doi:10.1177/0363546515589165

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Indiran, V., & Jagannathan, D. (2018). Osgood-Schlatter Disease. New England Journal of Medicine, 378(11), e15. doi:10.1056/NEJMicm1711831

Kabiri, L., Tapley, H., & Tapley, S. (2014). Evaluation and conservative treatment for Osgood-Schlatter disease: A critical review of the literature. International Journal of Therapy & Rehabilitation, 21(2), 91-96.

Mosich, G. M., Lieu, V., Ebramzadeh, E., & Beck, J. J. (2018). Operative treatment of isolated meniscus injuries in adolescent patients: A meta-analysis and review. Sports Health, 10(4), 311-316. doi:10.1177/1941738118768201

Scattone Silva, R., Nakagawa, T. H., Ferreira, A. G., Garcia, L. C., Santos, J. E., & Serrão, F. V. (2016). Lower limb strength and flexibility in athletes with and without patellar tendinopathy. Physical Therapy in Sport, 20, 19-25. doi:10.1016/j.ptsp.2015.12.001

Post 2

 

Patient Information:

XX, 42, Male

S.

CC: “lower back pain” 

HPI: 42 year old male who reports having pain in his lower back for the past month, which radiates to his left leg at times. 

Location:lower back

Onset: 1 month 

Character: unknown

Associated signs and symptoms:radiates to left leg at times 

Timing: unknown 

Exacerbating/ relieving factors: unknown 

Severity: unknown 

Current Medications: Unknown 

Allergies: Unknown  

PMHx: Unknown

Soc Hx: Unknown 

Fam Hx: Unknown 

ROS:

GENERAL:  Unknown

HEENT:  Unknown

RESPIRATORY:  Unknown

GASTROINTESTINAL:  Unknown

GENITOURINARY: Unknown

NEUROLOGICAL:  Unknown

MUSCULOSKELETAL:  Unknown

LYMPHATICS:  Unknown

PSYCHIATRIC:  Unknown

ALLERGIES:  Unknown

O.

HEENT:  Unknown

RESPIRATORY:  Unknown

GASTROINTESTINAL: Unknown

GENITOURINARY: Unknown

NEUROLOGICAL:  Unknown

MUSCULOSKELETAL:  Unknown

LYMPHATICS: Unknown 

Diagnostic results: Please note, diagnostic testing is not warranted without the first four week for the onset of back pain if neurological symptoms are not present (Dains, Baumann, & Scheibel, 2016, p. 295). 

• Straight leg raising (SLR): Assess for sciatic nerve root pain or a herniated disk (Dains, Baumann, & Scheibel, 2016, p. 293). 
• Radiographic pictures: Will rule out fracture, tumor, osteophytes, or a vertebral infection (Dains, Baumann, & Scheibel, 2016, p. 295). 
• Bone scan: Will look at blood flow and bone formation. Will show inflammation, infiltrations, and occult fractures. Can determine the risk of osteoporosis (Dains, Baumann, & Scheibel, 2016, p. 295).
• Electromyography: Will assess nerve root compression and the functionality of peripheral nerves (Dains, Baumann, & Scheibel, 2016, p. 295).
• Magnetic resonance imaging (MRI): Will measure soft tissue that would reveal a herniated disk, tumor, or a spinal cord pathologies (Dains, Baumann, & Scheibel, 2016, p. 295).
• Computed tomography (CT): Will aid in bone visualization (Dains, Baumann, & Scheibel, 2016, p. 295).
• Complete blood count (CBC): Will detect signs of anemia or infection that could be related to the development of an infection or tumor causing back pain (Dains, Baumann, & Scheibel, 2016, p. 295). 

A.

Differential Diagnoses

• Sciatica- Diagnosing is primarily done through history and physical exam. Often presents with lower back pain with additional pain in the leg. Most often caused by a herniated disk. Because of our patient presents with both of these symptoms, sciatica would be the probable diagnosis. The sciatic nerve would be the affected nerve (Verwoerd et al., 2014). 
• Herniated disk- Classified as lower back pain that can cause sciatica. Numbness and weakness are not typically experienced (Verwoerd et al., 2014). 
• Spinal fracture- Most commonly occurs in relation to a fall or heavy lifting. Found more frequently in the elderly population and could indicate an underlying diagnosis of osteoporosis (Enthoven et al., 2016). 
• Spinal metastasis- Would expect weight loss, fatigue, and anemia in conjunction with the back pain. A detailed health history would reveal other existing cancer or possibly a family history of cancer. Sensory and motor defects are typically present (Hohenberger et al, 2018). 
• Cauda Equina Syndrome- Develops from a lumbar herniated disk. Low back pain, bladder and bowel dysfunction, sexual dysfunction, and lower extremity sensory motor loss can be developing symptoms. Emergent intervention is necessary for this diagnosis (Ahad, Elsayed, & Tohid, 2015). 

P. 

Not required.

Additional Interview Questions

Obtain vital signs and determine if a fever is present. The presence of a fever could indicate an infectious or inflammatory process. Also determine if there has been any recent weight loss, intravenous drug use, or underlying immunosuppression (Dains, Baumann, & Scheibel, 2016, p. 288). 

Determine if the patient has undergone any recent trauma to the spinal cord that could have caused a fracture, dislocation, or sore muscles. Further assessment of the patient’s occupation and any possible strain to the lower back during day to day actives. Also inquiring about any existing medical conditions that the patient may have (Dains, Baumann, & Scheibel, 2016, p. 289). 

Systemic diseases, such as cancer and fibromyalgia should be ruled out. Furthermore, if the patient has an underlying diagnosis of cancer, tumor development on the spinal cord is at an increased risk (Dains, Baumann, & Scheibel, 2016, p. 289). 

Assessing the patient’s bowel and bladder function could signify nerve root compression related to a herniated disk, a nerve root entrapment, spinal stenosis, infection, or tumor. The incontinence of the bowel and bladder could indicate the presence of cauda equina syndrome (Dains, Baumann, & Scheibel, 2016, p. 290). 

A complete list of the patient’s medications could lead the advanced practice registered nurse (APRN) to possible lower back pain causes. For example, if the patient was using illegal intravenous drugs, an infectious process could have set it and could be affecting the back (Dains, Baumann, & Scheibel, 2016, p. 290). 

Obtaining detailed information about the back pain will aid the APRN in the cause of the back pain. Further information to obtain would include, characteristic of the pain, aggravating factors, and alleviating factors. A thorough assessment would also include questions asked about balance and gait changes. The APRN would also ask about the presence of numbness and tingling in the back or other extremities (Dains, Baumann, & Scheibel, 2016, p. 291-292). 

Additional Physical Examination 

Observe the patient’s overall appearance and movement. By watching the patient move you can determine asymmetrical movement that may be related to his underlying diagnosis. Vital signs will help determine an infectious process. Assess the skin looking for signs of a tumor or dermal cyst. Abnormalities of the head, eyes, ears, norse, and throat could signify an infectious process. By inspecting the back and extremities the APRN can assess for spinal alignment symmetry of both sides of the body. Percussion of the back and spine could uncover scolioses and would identify tenderness.Range of motion testing will help identify lumbar  mobility. Furthermore, an examination of the hip should include mobility, muscle strength, muscle circumference, neurological sensory function, deep reflexes and an assessment  to the abdomen (Dains, Baumann, & Scheibel, 2016, p. 294-295).

References

Ahad, A., Elsayed, M., & Tohid, H. (2015). The accuracy of clinical symptoms in detecting 

cauda equina syndrome in patients undergoing acute MRI of the spine. Neuroradiology 

Journal, 28(4), 438-442. doi:10.1177/1971400915598074

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical 

diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby. 

Enthoven, W. M., Geuze, J., Scheele, J., Bierma-Zeinstra, S. A., Bueving, H. J., Bohnen, A. M., 

& … Luijsterburg, P. J. (2016). Prevalence and “red flags” regarding specified causes of 

back pain in older adults presenting in general practice. Physical Therapy, 96(3), 

305-312. doi:10.2522/ptj.20140525

Hohenberger, C., Schmidt, C., Höhne, J., Brawanski, A., Zeman, F., & Schebesch, K. (2018). 

Effect of surgical decompression of spinal metastases in acute treatment – Predictors of 

neurological outcome. Journal Of Clinical Neuroscience: Official Journal Of The 

Neurosurgical Society Of Australasia, 5274-79. doi:10.1016/j.jocn.2018.03.031

Verwoerd, A. H., Peul, W. C., Willemsen, S. P., Koes, B. W., Vleggeert-Lankamp, C. M., el 

Barzouhi, A., & … Verhagen, A. P. (2014). Diagnostic accuracy of history taking to assess 

lumbosacral nerve root compression. The Spine Journal: Official Journal Of The North 

American Spine Society, 14(9), 2028-2037. doi:10.1016/j.spinee.2013.11.049

 

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To do a comment to each post with two credible reference each comment with citation above 2013

Post 1

Patient Information:

XX, 20, Male

S.

CC: “intermittent headaches” 

HPI: 20 year old male who complains of experiencing intermittent headaches, which diffuses all over his head. The great intensity and pressure occurs above the eyes and spreads to the nose, cheekbones, and jaw. 

Location: Generalized headache 

Onset: Unknown 

Character: Pressure 

Associated signs and symptoms: Greatest intensity above eyes and spreads to the nose, cheekbone, and jaw

Timing: Intermittent  

Exacerbating/ relieving factors: Unknown 

Severity: Unknown 

Current Medications: Unknown 

Allergies: Unknown  

PMHx: Unknown

Soc Hx: Unknown 

Fam Hx: Unknown 

ROS:

GENERAL:  Unknown

HEENT:  Unknown

GENITOURINARY: Unknown

NEUROLOGICAL:  Unknown

MUSCULOSKELETAL:  Unknown

LYMPHATICS:  Unknown

PSYCHIATRIC:  Unknown

ALLERGIES:  Unknown

O.

HEENT:  Unknown

GENITOURINARY: Unknown

NEUROLOGICAL:  Unknown

MUSCULOSKELETAL:  Unknown

LYMPHATICS: Unknown 

Diagnostic results:

• Mental Status Screen: The cause of a headache could have a life-threatening cause. Ruling out life threatening causes first is the priority. Completing a mental status screen  first is imperative to ensure the patient is fully orientated and able to provide a accurate health history (Dains, Baumann, & Scheibel, 2016, p. 221). 
• Determine the presence of a trauma. Bleeding can occur which can result in a sudden change in mental status (Dains, Baumann, & Scheibel, 2016, p. 223). 
• Determine the presence of any underlying chronic disease process. Patients who are immunocompromised are more likely to acquire an infection that could affect the brain. Furthermore, a headache could result from an electrolyte imbalance, blood sugar change, or hypercapnia to name a few (Dains, Baumann, & Scheibel, 2016, p. 223). 
• Complete blood count (CBC) with differential: Ordered to detect any abnormal lab findings (Dains, Baumann, & Scheibel, 2016, p. 229).
• Computed Tomography Scan (CT): Will detect any intracranial disease and should be completed with a new onset headache or in the presence of abnormal neurological findings (Dains, Baumann, & Scheibel, 2016, p. 229). 
• Lumbar Puncture: Will evaluate the cerebrospinal fluid pressure and can detect altered components, such as lymphocytes, glucose, protein, and bacteria. Would aid in detecting an infection of the central nervous system (Dains, Baumann, & Scheibel, 2016, p. 229).
• Erythrocyte Sedimentation Rate (ESR): Elevated in the presence of inflammation and is utilized when arteritis is suspected (Dains, Baumann, & Scheibel, 2016, p. 229).
• Skull Radiography- Utilized post trauma to view intracranial structures (Dains, Baumann, & Scheibel, 2016, p. 229). 

A.

Differential Diagnoses: 

• Tension-Type Headache (TTH): Most common adulthood headache. Often related to muscle contraction that could be caused by hunger, depression, or stress. Sign and symptoms include bilateral, generalized, or localized pain that distributes in the frontotemporal region. The level of pain can be mild to moderate with a throbbing, tight, or pressurized pain with a gradual onset. Duration is different for every patient, but can range from hours to months (Dains, Baumann, & Scheibel, 2016, p. 230; Kim et al., 2017)
• Mixed Headache: Occurs from muscular and vascular contraction. The pain is often described as throbbing with a constant pain while the patient is awake. Further symptoms include tightness, pressure, and muscle contraction. This is a possible diagnosis, but not expected due to the patient not complaining of muscle contraction (Dains, Baumann, & Scheibel, 2016, p. 230). 
• Sinusitis: Would be consider a secondary headache because it is caused by another disease process. Sore throat, postnasal discharge, and facial pain are often seen in conjunction with the headache. Specifically, pain occurs over the affected sinuses. This is a possible diagnosis, but additional respiratory symptoms would be expected if it were the cause (Dains, Baumann, & Scheibel, 2016, p. 230). 
• Cluster headache: Onset is typically abrupt, occurs at night, and seen mostly in men. Pain is described as as severe, burning, piercing, or neuralgic. An episode can be 15 minutes to 2 hours at a time. The patient will experience several episodes in a cluster of time. Each cluster ranges from days to weeks. Other symptoms seen with a cluster headache are ipsilateral rhinorrhea, conjunctivitis, facial sweating, ptosis, and eyelid edema. Headaches are brought on by the consumption of alcohol, stress, and heat or wind exposure. Overall, the patients clinical presentation does not match cluster headaches (Dains, Baumann, & Scheibel, 2016, p. 230; Weaver-Agostoni, 2013). 
• Dental disorders: The presence of a tooth abscess or nerve root dysfunction could cause a headache with associate facial pain. The oral inspection of the mouth may reveal redness or area of infection. The oral mucosa will also be tender to touch. This is a possible diagnose for out patient, but not likely given we do not know the results of his oral exam (Dains, Baumann, & Scheibel, 2016, p. 230). 

P. 

Not required.

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical 

diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Kim, J., Cho, S., Kim, W., Yang, K. I., Yun, C., & Chu, M. K. (2017). Insomnia in tension-type 

headache: A population-based study. The Journal Of Headache And Pain, 18(1), 95. doi:

10.1186/s10194-017-0805-3

Weaver-Agostoni, J. (2013). Cluster headache. American Family Physician, 88(2), 122-128.

Post 2

 

Patient Information:

XX, 47, F, Caucasian

S.

CC   pain in R) wrist.

HPI: This is 47 year old white female who developed pain in her right wrist 2 weeks ago.  The pain causes her to drop her hairstyling tools.  She also has numbness and tingling in her right thumb, index and middle fingers.

Location: wrist

Onset: two weeks ago

Character: pain 

Associated signs and symptoms: numbness and tingling in the thumb and index and middle fingers

Timing: not shared

Exacerbating/ relieving factors: when working the pain in her wrist causes her to drop her hair-styling tools

Severity: not shared

Current Medications: not shared

Allergies: none shared

PMHx: not shared

Soc Hx:  occupation of a cosmetologist

Fam Hx: not shared

ROS: Example of Complete ROS:

GENERAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  No burning on urination. Pregnancy not shared. Last menstrual period not shared

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia. Numbness and tingling in the thumb, index and middle finger on the right extremity. No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain or stiffness.  Has joint pain in the right wrist.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

O.

Physical exam: no information provided.

Diagnostic results: X-ray of wrist – may reveal osteophytes, loss of joint space and fracture (Dains, Baumann & Scheibel, 2016).  ESR – indicative of inflammation help in diagnosing arthriris (Dains, Baumann & Scheibel, 2016).  Nerve conduction studies confirm carpal tunnel syndrome by detecting median nerve entrapment (Wipperman & Goerl, 2016). 

A.

Differential Diagnosis

Carpal tunnel syndrome

Wrist fracture

Fibromyalgia

Osteoarthritis

Tenosynovitis

Carpal tunnel syndrome will have patients presenting with weakness of the hand, dry skin over distribution of the medial nerve; history of repetitive movement, parathesia, weakness and clumsiness of affected hand (Dains, Baumann & Scheibel, 2016).  Cardinal symptoms of carpal tunnel will have patient presenting with pain and paresthesia in the distribution of the median nerve, this includes the thumb, index and middle finger; patients will have difficulty holding objects (Wipperman & Goerl, 2016).   The patient is presenting with the signs and symptoms that align with the description.

Wrist Fracture will have a patient presenting wit wrist pain that is worse with palpation; patient usually has history of a fall on an outstretched hand and will have pain and swelling of the wrist (Dains, Baumann & Scheibel, 2016).  Patients with a wrist fracture will present with pain, radial tenderness, swelling, wrist deformity, hematoma and decreased range of motion (Brants & IJsseldijk, 2015).   

Fibromyalgia will have the patient presenting with trigger points on palpation that produce pain, general muscle and joint aches, occurring to those who have a history of depression, sleep disturbance and chronic fatigue (Dains, Baumann & Scheibel, 2016).  Patients with fibromyalgia will have tenderness upon palpation of pressure, and chronic pain disorders, widespread pain and no diagnostic tests available to diagnose (Horowitz, 2015).

Osteoarthritis will have patients who present with asymmetrical joint pain and stiffness that improves throughout the day, history of joint trauma and are obese; joints will be enlarged with limited range of motion (Dains, Baumann & Scheibel, 2016).  Osteoarthritis has patient’s complaints to be that of joint pain, pain that is disabling to them; this can cause neuropathy to the structure (POLAT, DOGAN, SEZGIN OZCAN, KOSEOGLU & KOCKER AKSLEIM, 2017).  Patients at an increased risk will have a history of repetitive weight lifting tasks, some form of joint trauma, are obese or have been diagnosed with diabetes mellitus (Dains, Baumann & Scheibel, 2016). 

Tenosynovitis will have patients’ present with pain with movement, swelling over the tendon, crepitus, and history of repetitive trauma of occupational activities, range of motion can be limited (Dains, Baumann & Scheibel, 2016).   Tenosynovitis commonly effects the forth extensor compartment and presents as a mass with wrist pain and limited range of motion (Ichihara et al., 2015).  Tenosynovitis can present when patients have other chronic medical diagnosis such as gout, rheumatoid arthritis, diabetes mellitus and hyperparathyroidism (Ichihara et al, 2015).

P. 

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Brants, A., & IJsseldijk, M. A. (2015). A pilot study to identify clinical predictors for wrist fractures in adult patients with acute wrist injury. International Journal Of Emergency Medicine, 8(1), 1-5. doi:10.1186/s12245-015-0050-y

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Horowitz, S. (2015). Current Understanding of Fibromyalgia: Diagnosis, Treatment, and Theories About Causes. Alternative & Complementary Therapies, 21(1), 25-31. doi:10.1089/act.2015.21101

Ichihara, S., Hidalgo-Diaz, J., Prunières, G., Facca, S., Bodin, F., Boucher, S., & Liverneaux, P. (2015). Hyperparathyroidism-related Extensor tenosynovitis at the Wrist: a general review of the literature. European Journal Of Orthopaedic Surgery & Traumatology, 25(5), 793-797. doi:10.1007/s00590-015-1596-3

POLAT, C. S., DOĞAN, A., SEZGİN ÖZCAN, D., KÖSEOĞLU, B. F., & KOÇER AKSELİM, S. (2017). Is There a Possible Neuropathic Pain Component in Knee Osteoarthritis?. Archives Of Rheumatology, 32(4), 333-338. doi:10.5606/ArchRheumatol.2017.6006

Wipperman, J., & Goerl, K. (2016). Carpal Tunnel Syndrome: Diagnosis and Management. American Family Physician, 94(12), 993-999.

 

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To do a comment to the post below in APA style with citation, needs 2 credible reference from 2013 and above.

Episodic/Focused SOAP Note Template

Patient Information:

J, 11, Male, XX (Race) 

S.

CC: “Mild ear ache”

HPI: The patient is 11 year old XX male who presented himself with a mild right ear ache, which started two days ago. Associated symptom include possible fever, right ear pain, difficulty hearing from the right ear. Associated symptom are exacerbated with sleep. 

Current Medications: Inquire if patient is currently taking any medications, rule out earring loss related to medication toxicity. 

Allergies: Inquire about allergies. 

PMH: Inquire if patient has a history of acute otitis media or underlying hearing loss. Inquire if patient has had tonsillectomy or an adenoidectomy in the past.
SH: Spends time in pool during summer. 

FH: Inquire if family members have history of hearing loss. 

ROS:

• GENERAL: Possible fever. Inquire about patient’s swimming habits and ask if ear plugs used. Determine method of cleaning ear. 
• HEENT: Right ear pain. Inquire if patient has tinnitus, discharge from ear, vertigo, or itchiness. Inquire if patient has a history of acute otitis media, hearing loss, vertigo, tinnitus, discharge from ear canal.
• RESPIRATORY: Inquire if patient has had post nasal discharge or sputum production and ask about color of mucous. 
• ALLERGIES:  Unknown 

O.

Physical exam:

• HEENT— Assess outer ear and note surrounding tissue, shape, color, and any lesions. Assess the external ear for discharge or any odor. Assess for the placement of a foreign object in ear. Assess for tenderness on the outer ear near the auricle and mastoid. Tenderness could indicate a possible infection. Use otoscope to assess external and middle ear. At this time, assess for erythema, lesions, and discharge. Inspect tympanic membrane for perforations. Assess the frontal and maxillary sinuses for swelling. No tenderness or swelling over the soft tissue should be present. Assess tonsils and inside of mouth for lesions, erythema, and swelling. 
• RESPIRATORY: Determine if upper respiratory infection is present, assess for clear lungs. 

Diagnostic results: 

• Whispered Voice- Determines if patient is able to hear whispering. If they do not pass this test, hearing loss could be assumed. (Ball, Dains, Flynn, Solomon, Stewart, et al., 2015, p. 241). 
• Weber Test- Determines unilateral hearing loss (Ball et al., 2015, p. 241). 
• Rinne Test- Determines if the patient conducts sound better through bone or air. The patient should hear the sound conducted through the air twice as long (Ball et al., 2015, p. 241)
• Culture of ear fluid (Attlmayr, 2015). 

Differential Diagnoses

• Otitis externa 
  • Often seen with individuals that swim. This infection is located on the outer ear. Pain is worse when an otoscope is inserted because sensitivity is on the outer ear. The outer portion of the ear is often inlamted and tender to touch. When inspecting the ear, the ear canal would appear narrow. Because of the narrowing, fluid is unable to drain from the ear (Rosenfeld et al., 2014). 
• Otitis media
  • Otitis media is a middle ear infection that usually presents unilaterally, hearing loss is present, and tympanic membrane is pink. Pus often forms inside the ear, which could cause perforation of the tympanic membrane. Ear pain, fever, difficulty hearing, irritability, and lethargy can also accompany this diagnosis. While examining the ear with the otoscope, erythema, dullness, decrease light reflex, and bulging of the tympanic membrane (Nash, 2013). 
• Eustachian catarrh 
  • Often results after an upper respiratory infection. It would be essential to determine if the patient has has a recent upper respiratory tract infection. Fluid collects in the eustachian tube, which causes pain and trouble hearing (Nash, 2013). 
• Cholesteatoma 
  • The growth of a skin tag inside the ear, behind the ear drum. The patient could be born with it or it can develop after several ear infections. It would be essential to determine if the patient has had frequent ear infections in the past (Chawla, Ezhil Bosco, Lim, Shenoy, & Krishnan, 2015). 
• Mastoiditis
  • Mastoiditis is a common complication of acute otitis media. Pain, erythema, and tenderness are typically present alone the mastoid process (Attlmayr, 2015). 

P.  NA

Reference

Attlmayr, B., Zaman, S., Scott, J., Derbyshire, S. G., Clarke, R. W., & De, S. (2015). 

Paediatric acute mastoiditis, then and   now: Is it more of a problem now?. The Journal 

Of Laryngology And Otology, 129(10), 955-959. doi:10.1017/S0022215115002078

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S.,   Stewart, R. W. (2015). Seidel’s guide to physical 

examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Chawla, A., Ezhil Bosco, J. I., Lim, T. C., Shenoy, J. N., & Krishnan, V. (2015). Computed tomography 

features of external auditory canal cholesteatoma: A pictorial review. Current Problems In 

Diagnostic Radiology, 44(6), 511-516. doi:10.1067/j.cpradiol.2015.05.001

Nash, L. (2013). A case study on prescribing for an acute ear infection in a child. Nurse Prescribing, 

11(4), 179-184.

Rosenfeld, R. M., Schwartz, S. R., Cannon, C. R., Roland, P. S., Simon, G. R., Kumar, K. A., & … 

Robertson, P. J. (2014). Clinical practice guideline: Acute otitis externa. Otolaryngology-Head & 

Neck Surgery, 150S1-S24. doi:10.1177/0194599813517083

 

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TO REPLY TO EACH COMMENT WITH APA, CITATION AND REFERENCE ABOVE 2013.

Post 1

Introduction

According to week two, it is clear that the assessment tools used in psychotherapy have two primary purposes. The first purpose is to measure the illness and diagnose clients while the second purpose is to evaluate a client’s response to treatment. There are different types of assessment tools, but in this discussion, I have selected Patient Stress Questionnaire.

The psychometric properties of the Patient Stress Questionnaire as the selected assessment tool

Patient Stress Questionnaire refers to the tool employed in primary care settings to help in screening for the behavioral health symptoms.  The instrument was adapted from the PHQ-9, AUDIT, GAD-7, and PC-PTSD.  Patient Stress Questionnaire is made up of a list of items that efficiently help in identifying the potential behavioral health problems. The tool is a 24-item behavioral health screening tool which is composed of a collection of twelve (12) separate “ultra-brief” screening tools to offer a preliminary mental health and addiction diagnosis. The PHQ-9 is made up of 9 items which represent the criterion symptoms for DSM 5 major depressive disorder. These have questions related to how much sign has bothered the client based on the scale such as  “not at all,” “nearly every day,” and  “several days”. The GAD-7 is made up of seven items with the response similar to PHQ-9 and scored as a continuous variable from 0 to 21 (Kroenke et al. 2016).

When it is appropriate to use Patient Stress Questionnaire

The tool is used when the client is suspected to have depression and anxiety. Several well-validated measures can be used to assess depression and anxiety as separate domains (Flückiger et al 2016), but the advantage of Patient Stress Questionnaire is that it is a measure that offers a single composite score for both the depression and anxiety (Kroenke et al. 2016). The tool is used in assessing depressive symptoms among patients having conditions such as aphasia. The tool is applicable for measuring perceived stress (Laures-Gore et al. 2017).

Furthermore, theoretical and empiric evidence of overarching psychological construct that compromise of distinct but related dimensions of anxiety and depression. Therefore, the intercorrelation between depression and anxiety makes Patient Stress Questionnaire attractive as it provides a composite score.

Based on the efficacy of Patient Stress Questionnaire in evaluating psychopharmacologic medications, psychopharmacological medications aim to manage behavior, stabilize mood, or to treat psychiatric disorders and their associated symptoms. On the other hand, Patient Stress Questionnaire is used to screen for these behavioral health symptoms and therefore, can be used to determine whether the symptoms are reducing or not based on the psychopharmacological medications. The tool can be used to  self-report symptoms and to identify  persistent symptoms of anxiety disorders and even monitor the treatment in clinical practice (Rose & Devine, 2014).

                                                     References

Kroenke, K., Wu, J., Yu, Z., Bair, M. J., Kean, J., Stump, T., & Monahan, P. O. (January 01, 2016). Patient Health Questionnaire Anxiety and Depression Scale: Initial Validation in Three Clinical Trials. Psychosomatic Medicine, 78, 6.

Laures-Gore, J. S., Farina, M., Moore, E., & Russell, S. (January 01, 2017). Stress and depression scales in aphasia: Relation between the aphasia depression rating scale, stroke aphasia depression questionnaire-10, and the perceived stress scale. Topics in Stroke Rehabilitation, 24, 2, 114-118.

Rose, M., & Devine, J. (January 01, 2014). Assessment of patient-reported symptoms of anxiety. Dialogues in Clinical Neuroscience, 16, 2, 197-211.

Flückiger, C., Forrer, L., Schnider, B., Bättig, I., Bodenmann, G., & Zinbarg, R. E. (January 01, 2016). A Single-blinded, Randomized Clinical Trial of How to Implement an Evidence-based Treatment for Generalized Anxiety Disorder [IMPLEMENT] — Effects of Three Different Strategies of Impleme

Post 2

psychometric properties of the Screening, brief intervention, and referral to treatment (SBIRT) tool

The SBIRT grant program was developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) which provided either brief intervention/treatment or referred to appropriate services for individuals who use alcohol or psychoactive substances, not including tobacco that may not meet criteria for a substance use disorder (Aldridge, Linford, & Bray, 2017).  It begins with a pre-assessment screening which briefly explores substance use.  If a positive pre-screen is evident, the provider should move to the Alcohol use disorders identification test (AUDIT) and/or the Drug abuse screening test (DAST) for more thorough assessment.  If positive brief intervention or treatment is advised (“Clinician Tools – SBIRT for Substance Abuse,” n.d.).  According to Yong, et al. as part of their systematic review, it is unclear whether it is beneficial to utilize brief interventions as part of the SBIRT screened individuals who were not seeking treatment at the time of assessment (2014).  Evaluation of this project indicated that the program was positively correlated with decreased alcohol and/or substance use in this population.  However, it is unclear whether other factors were key (Aldridge et al., 2017).  It was noted however that participants had significantly lower reports of substance use one month after intervention.  However limitations in study design may have impacted the reported results (Aldridge et al., 2017).

Explain when it is appropriate to use SBIRT with clients

Each client should be assessed using a pre-assessment screening tool yearly.  If positive, the client should be assessed using the AUDIT or DAST tools as indicated above (“Clinician Tools – SBIRT for Substance Abuse,” n.d.)

Is the SBIRT tool appropriate to evaluate the efficacy of psychopharmacologic medications

The SBIRT protocol moves to brief intervention or brief treatment as appropriate.  These interventions are focused on psychological treatments 5-60 minutes in length (“Clinician Tools – SBIRT for Substance Abuse,” n.d.)  As such, they would not be involving psychopharmacological substances, at least initially it would not be appropriate for evaluation of medication effectiveness.

References

Aldridge, A., Linford, R., & Bray, J. (2017). Substance use outcomes of patients served by a large US implementation of Screening, Brief Intervention and Referral to Treatment (SBIRT). Addiction, 112, 43–53. https://doi.org/10.1111/add.13651

Clinician Tools – SBIRT for Substance Abuse. (n.d.). Retrieved September 5, 2018, from http://www.sbirt.care/tools.aspx

Young, M. M., Stevens, A., Galipeau, J., Pirie, T., Garritty, C., Singh, K., … Moher, D. (2014). Effectiveness of brief interventions as part of the Screening, Brief Intervention and Referral to Treatment (SBIRT) model for reducing the nonmedical use of psychoactive substances: a systematic review. Systematic Reviews, 3, 50. https://doi.org/10.1186/2046-4053-3-50

 

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