ADMISSION HISTORY AND PHYSICAL

Patient Name: Jonathan Jones                                                                                        MR#: 44579

Attending Physician: Ajay Shah, M.D.                                                                    DOB: 12/24/89

Chief Complaint: 27 yo [year old] male presents with 2 days of worsening right lower quadrant belly pain, nausea, and vomiting.

History of Present Illness (HPI): 2 days prior to admission, the patient began complaining of diffuse belly pain that initially felt like indigestion. Over the course of the day, this pain grew progressively worse, localizing in the right lower quadrant. This pain became constant and dull and radiated to the back. The evening prior to admission the patient was awakened by pain and nausea. He drank some Alka-Seltzer and attempted to return to sleep, shortly after which he began vomiting nonbloody or bilious emesis. Shortly thereafter, the patient decided to come to the ED [Emergency Department].

The patient indicates he did have a fever but did not take his temperature. He denies chills, testicular pain, blood in the stool, or recent weight change. The patient’s last bowel movement was yesterday, with some small amounts of mucus but otherwise normal. He notes a history of irritable bowel syndrome. However, he states that this pain is different than the pain he has had in the past.

Past Medical History (PMH): Irritable bowel syndrome, last exacerbation 6 months ago. The rest of the past medical history is unremarkable.

Past Surgical History (PSH): Tonsillectomy and adenoidectomy in early childhood. Umbilical hernia repair at age 4.

Medications: None.

Allergies: NKDA

Social History: The patient is employed as a computer programmer. He is married and has no children. He has a 10-year pack-history (in this case, 5 years, two packs a day) of smoking. He drinks alcohol rarely.

Family History: Both parents are alive and well. One sister has a history of GERD.

Review of Systems: 12-point review of systems was performed and was negative except for those items noted in the HPI above.

Physical Examination

General: The patient is an alert and oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78. Pulse 68 and regular. Temperature 38.56°C (101.4°F).

HEENT: Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears clear. Throat normal.

Neck: The neck is supple with no carotid bruits.

Lungs: The lungs are clear to auscultation and percussion.

Heart: RRR, no m/g/r.

Abdomen: Nondistended. Bowel sounds are normal. There is rebound tenderness on the left side, with discomfort and guarding upon palpation in the right lower quadrant, and positive psoas sign [pain on extension of right thigh with patient lying on left side].

Extremities: No clubbing, cyanosis, or edema, distal extremities warm and well perfused.

Laboratory Data: Hemoglobin 14.6, hematocrit 43.6, WBC 13,000, sodium 138, potassium 3.8, chloride 105, CO2 24, BUN 10, creatinine 0.9, glucose 102. Urinalysis was negative.

Diagnostic Studies: Flat plate and upright films of the abdomen revealed a diffuse small bowel distension with no evidence of free air in the abdomen. CT of the abdomen indicated a thickened cecal wall and dilated appendix.

Assessment/Impression: 27 yo male with PMH significant for irritable bowel syndrome presents with clinical signs of acute onset appendicitis.

Plan: The patient will be admitted and kept NPO, and a laparoscopic appendectomy will be performed in the morning.

Rogers, M.D.

Admission H and P performed and dictated by Dr. Ajay Shah for Dr. Rogers.

Discussion Questions

1. Why is it important that the admitting doctor record information about the patient’s heart, lungs, and other body systems when the pain is in the patient’s abdomen?
2. How would you find out what the abbreviation HEENT means? What are some of the other abbreviations used in this case study, and what do they mean?
3. Using what you’ve learned about word parts, describe the types of surgeries listed in the patient’s past surgical history.
4. The extremities are described as “No clubbing, cyanosis, or edema.” Edema is explained in this chapter. Look up what the other two terms mean.

Your answers need to be typed as complete sentences and be thorough and detailed for full credit.

 

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1. The assessment tasks requires you to:
   1. Identify and discuss two (2) signs or symptoms of clinical deterioration associated with the presenting problem, from chosen case study. This discussion should consider the potential impact of case study data (e.g. pathology results, past medical history) on the health status of the patient in the chosen case.
   2. Following on from your presented discussion associated with point one (1), develop a clinical plan of care which identifies:
    

One (1) priority of clinical care and; 

Discuss three (3) nursing interventions that directly address the identified clinical priority. The discussion should refer to relevant clinical assessments. Measurable outcome parameters for each intervention will be discussed to justify the intervention and evaluate its efficacy. Discussion is to be supported with contemporary research. 

 

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Assignment Details:

Perform the following tasks:

· To complete this assignment:

–  Review the case study and select one of the committee roles.

– Your selection as a member on the committee 

–  Identification one or more issues, related to your role on the committee

–  Identification of probable cause(s) of identified issue(s)

–  Proposed recommendations to resolve the identified issues 

–  Reference slide – list of academic references, using APA style 

  

 Case Study

Read the following case study

A good friend of yours is director of nursing at a 220-bed community hospital. Last year the hospital merged with a much larger medical center. One of the upsides, as well as one of the challenges, resulting from this change has been the rapid introduction of new computer systems. The goal is to bring the hospital “up to speed” within 3 years. At present, the Computerized Physician Order Entry (CPOE) is being implemented. The general medical and surgical units went live last month. The ICU, pediatrics, and obstetrics units are scheduled to go live next month. The plan is to work out any kinks or problems on the general units and then go live in the specialty units. Most of the physicians, nurse practitioners, and physician assistants initially complained but are now becoming more comfortable with the computers and are beginning to integrate the CPOE process into their daily routines. Several physicians are now requesting the ability to enter orders from their offices and others are looking into this option. However, three physicians have not commented during this process but are clearly resisting. For example, after performing rounds and returning to their offices they called the unit with verbal orders. After being counseled on this behavior, they began to write the orders on scraps of paper and put these in the patient’s charts or leave them at the nurses’ station. When they were informed that these were not “legal orders,” they began smuggling in order sheets from the non-activated units. In addition, they have been coercing the staff nurses on the units to enter the orders for them. This has taken two forms. Sometimes they sign in and then ask the nurses to enter the orders. Other times they ask the nurses to put the orders in verbally and then they confirm the orders. The nurses feel caught between the hospital’s goals and the need to maintain a good working relationship with these physicians. 

You suggest to your friend (director of nursing) to create an informal committee to review the issues surrounding the CPOE implementation. The committee would determine methods to address these issues, prior to implementing CPOE within the ICU, pediatrics, and obstetrics units. Your friend appreciates the suggestion and forms a small committee with the following members:

· Taylor Terrific, RN – a nurse practitioner

· Dr. Dudley Do-Right – a physician who uses the CPOE system routinely and correctly

· Dr. Frank Burns – a physician who rarely, if ever, uses the CPOE system

The director of nursing asks each committee member to create a short PowerPoint presentation for the committee. The presentation would identify issues that occurred during CPOE implementation, identify potential causes of such issues, and list specific recommendations, based on strong rationale and research, to resolve the identified issues prior to the next CPOE implementation. Each committee member will have a unique perspective, based on their position (i.e., nurse, physician).

  

   

 

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Mary is a 35 years old electrical engineer who presents to the office for evaluation of a rash on her face that has been present for 1 week. She denies new soaps, detergents, lotions, environmental exposures, medications, and foods. The rash is across her face and the bridge of her nose. She states that she first noticed it after spending a week hiking and camping in the Appalachians. The lesions itch and are painful. She has not tried anything to make it better, but she has noticed that going outdoors makes it worse. She denies any spread of the rash to other areas. She has never had this rash before.

She has noticed some increased fatigue, fever, and weight loss. She denies headache, sore throat, ear pain, nasal or sinus congestion, chest pain, shortness of breath, cough, abdominal pain, and pain with urination, constipation, or diarrhea. She does have mouth soreness. She has noticed some increased muscle aches and pains, which are worse in the hand and wrist. She denies early morning joint stiffness or difficulty with being able to move in the morning. She denies temperature intolerance, polyuria, polydipsia, or polyphagia.

She had a tonsillectomy at age 9 for chronic strep throat infections. She has been healthy as an adult. She has never had children. She has never been hospitalized for any reason.

Her family history is significant for a mother with rheumatoid arthritis. Her father is healthy.

She does not smoke; she drinks a glass of wine nearly every night with her dinner; she denies illicit drug use. She completed a master’s degree in engineering. She has lived with her boyfriend for the past 5 years.

Patient is an alert young woman, sitting comfortably on the examination table. BP 112/66 mm Hg; HR 62 BPM and regular; respiratory rate 12 breaths/min; temperature 100.3°F. Several erythematous plaques scattered over the cheeks and the bridge of nose, sparing the nasolabial folds. Normocephalic, atraumatic. Sclera white, conjunctivae clear; pupils constrict from 4 mm to 2 mm and equal, round, and reactive to light and accommodation. Oropharynx moist with erythema in the posterior pharyngeal wall; no exudates; shallow ulcers in the buccal mucosa bilaterally. Neck supple without cervical lymphadenopathy or thyromegaly. Full range of motion; no swelling or deformity; muscles with normal bulk and tone.

Instructions:

    Make a whole history and physical examination in a comprehensive manner with all its elements included: CC, HPI, PMH, FH, SH, MEDICATIONS, ALLERGIES, ROS PER APPARATUS OR SYSTEMNS, HEAD TO TOE PHYSIACL EXAMINATION PER SYSTEMS ( write your presentation in H&P format no paragraph format).

 

          Based on this information, what is your presumptive nursing diagnosis? All nursing diagnosis that apply to the case written in NANDA format related to … and evidence by…., NO MEDICAL DIAGNOSIS.

  Teaching plan and nursing care plan per each nursing diagnosis on this case.

Requirements.

          1- All written assignment and documentations must be  in APA 6th edition format.

          2- Double spaces, minimum 4 pages long , minimum 3 up to date bibliography. (UP to date means last 3 years.), Note: you can use your test book as bibliography too, bibliography have to be written in APA format.

 

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Case Study I A 45-year-old female presents to your clinic today with complaints of back pain and “just not feeling good”.  Regarding her back, she states that her back pain is a chronic condition that she has suffered with for about the last 10 years. She has not suffered any specific injury to her back. She denies weakness of the lower extremities, denies bowel or bladder changes or dysfunction, denies radiation of pain to the lower extremities and no numbness or tingling of the lower extremities. She describes the pain as a constant dull ache and tightness across the low back. She states she started a workout program about 3 weeks, and she is working out with a friend that is a body builder. She states her friend suggested taking Creatine to help build muscle and Coenzyme Q10 as an antioxidant so she started those medications at the same time she began working out. She states she also takes Kava Kava for her anxiety and garlic to help lower her blood pressure. Past medication history includes: Type II diabetes since age 27, High blood pressure, Recurrent DVT’s Her other medications include: Glyburide 3 mg daily with breakfast, Lisinopril 20 mg daily and Coumadin 6 mg daily 1.What are your findings following reviewing this medication list? Explain concerns in detail. 2.Is there additional information you would obtain? If so, please discuss rationale. 3.What are your recommendations for managing this patient’s medications? 4.What are the components for educating the patient? 5.If your plan is to prescribe a medication/s, create a prescription and discuss, what are the important components necessary on the packaging or on the label? Please answer each question concisely. You do not need to write a long paragraph to prove your points. You need to provide a cover page and 1 reference page. Support answers with peer reviewed journals. Articles cannot be older than 5 years. Remember all paragraphs need to be cited properly, and the paper must be written in APA 6th format. A minimum of 3 references are required for this case study.

 

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