Read the following chapters in Financial Management for Nurse Managers and Executives, 5 ed., Jones (2019):
Chapter 3- The financing of health care
Chapter 4- Key issues in applied economics
Chapter 6 – Accounting Principles
Write 150-300 words post Identifying healthcare FINANCIAL MANAGEMENT ISSUES for nurse managers.
You may use Google scholars or any other nursing journal or book.
Make sure all reference sources are within 5 years.
APA format.
Plagiarism receipt requires
It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span.
Evaluate the Health History and Medical Information for Mr. M., presented below.
Based on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay assignment, as instructed below.
Health History and Medical Information
Health History
Mr. M., a 70-year-old male, has been living at the assisted living facility where you work. He has no know allergies. He is a nonsmoker and does not use alcohol. Limited physical activity related to difficulty ambulating and unsteady gait. Medical history includes hypertension controlled with ACE inhibitors, hypercholesterolemia, status post appendectomy, and tibial fracture status postsurgical repair with no obvious signs of complications. Current medications include Lisinopril 20mg daily, Lipitor 40mg daily, Ambien 10mg PRN, Xanax 0.5 mg PRN, and ibuprofen 400mg PRN.
Case Scenario
Over the past 2 months, Mr. M. seems to be deteriorating quickly. He is having trouble recalling the names of his family members, remembering his room number, and even repeating what he has just read. He is becoming agitated and aggressive quickly. He appears to be afraid and fearful when he gets aggressive. He has been found wandering at night and will frequently become lost, needing help to get back to his room. Mr. M has become dependent with many ADLs, whereas a few months ago he was fully able to dress, bathe, and feed himself. The assisted living facility is concerned with his rapid decline and has decided to order testing.
Objective Data
Laboratory Results
Critical Thinking Essay
In 750-1,000 words, critically evaluate Mr. M.’s situation. Include the following:
You are required to cite to a minimum of three sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.
Prepare this assignment according to the guidelines found in the APA Style Guide
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
Chapter 3 describes Standards of Practice. Create a PowerPoint or Prezi describing the 6 Standards of Practice and the 11 standards of professional performance. There should be one slide for each standard, except for #5, which should have 4 slides. See Table 3.1. Each slide should have the standard, a scholarly description of the standard, and one example of what a School Nurse might do to meet the standard.
ExploreHealthCareers.org has a partial listing of potential allied health careers. Medical Administrative Assistants, entry level Medical Billing and Coding, Medical Assistant, Electronic Health Records Specialist are all entry level positions. In 1-2 pages reflect on where you might like your career to go.
Include the following aspects in the assignment:
Ø Convey two careers listed in either the link above or other links pertaining allied health careers.
Ø Expand on the job outlook, responsibilities, and education requirements.
Ø Demonstrate what skills you personally have that would make you successful in the field of Allied Health.
Ø Explore your short and long-term goals in reference to Allied Health.
INSTRUCTIONS:
1. Go to https://health.gov/healthypeople/objectives-and-data/browse-objectives. “Healthy People 2030 objectives are organized into intuitive topics so you can easily find the information and data you’re looking for. Pick a topic you’re interested in and explore the relevant objectives.” (Healthy People 2020).
2. From any of the health conditions, health behaviors, populations, settings and systems and social determinants of health, choose three conditions or problems that are affecting our community and present a PowerPoint presentation. The presentation must include the following.
a. Mention and discuss “The Healthy People 2030” goals for the conditions, objectives to control or eradicate the conditions, the emergency preparedness and the role of our health care system in the prevention, control and/or eradication of the conditions chosen.
3. Identify the epidemiologic principles that were applied based on what you studied on the lecture.
4. The application of the three levels of prevention to each one of the conditions identified.
5. Mention and discuss how the three conditions affect your community.
The presentation must be in APA PowerPoint format with a minimum of 15 slides (excluding first and references page). A minimum of 4 evidence-based references including the “Healthy People 2030” must be used. You must use the required APA font.
Mrs. G, a 55 year old Hispanic female, presents to the office for her annual exam. She reports that lately she has been very fatigued and just does not seem to have any energy. This has been occurring for 3 months. She is also gaining weight since menopause last year. She joined a gym and forces herself to go twice a week, where she walks on the treadmill at least 30 minutes but she has not lost any weight, in fact she has gained 3 pounds. She doesn’t understand what she is doing wrong. She states that exercise seems to make her even more hungry and thirsty, which is not helping her weight loss. She wants get a complete physical and to discuss why she is so tired and get some weight loss advice. She also states she thinks her bladder has fallen because she has to go to the bathroom more often, recently she is waking up twice a night to urinate and seems to be urinating more frequently during the day. This has been occurring for about 3 months too. This is irritating to her, but she is able to fall immediately back to sleep.
Current medications: Tylenol 500 mg 2 tabs daily for knee pain. Daily multivitamin PMH: Has left knee arthritis. Had chick pox and mumps as a child. Vaccinations up to
date.
GYN hx: G2 P1. 1 SAB, 1 living child, full term, wt 9lbs 2 oz. LMP 15months ago. No history of abnormal Pap smear.
FH: parents alive, well, child alive, well. No siblings. Mother has HTN and father has high cholesterol.
SH: works from home part time as a planning coordinator. Married. No tobacco history, 1-2 glasses wine on weekends. No illicit drug use
Allergies: NKDA, allergic to cats and pollen. No latex allergy Vital signs: BP 129/80; pulse 76, regular; respiration 16, regular
Height 5’2.5”, weight 185 pounds
General: obese female in no acute distress. Alert, oriented and cooperative. Skin: warm dry and intact. No lesions noted
HEENT: head normocephalic. Hair thick and distribution throughout scalp. Eyes without exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
CV: S1 and S2 RRR without murmurs or rubs
Lungs: Clear to auscultation bilaterally, respirations unlabored.
Abdomen– soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT.
Labwork:
CBC: WBC 6,000/mm3 Hgb 12.5 gm/dl Hct 41% RBC 4.6 million MCV 88 fl MCHC
34 g/dl RDW 13.8%
UA: pH 5, SpGr 1.013, Leukocyte esterase negative, nitrites negative, 1+ glucose; small protein; negative for ketones
CMP:
Sodium 139
Potassium 4.3
Chloride 100
CO2 29
Glucose 95
BUN 12
Creatinine 0.7
GFR est non-AA 92 mL/min/1.73 GFR est AA 101 mL/min/1.73 Calcium 9.5
Total protein 7.6 Bilirubin, total 0.6 Alkaline phosphatase 72
AST 25
ALT 29
Anion gap 8.10
Bun/Creat 17.7
Hemoglobin A1C: 6.9 %
TSH: 2.35, Free T 4 0.7
Cholesterol: TC 230 mg/dl, LDL 144 mg/dl; VLDL 36 mg/dl; HDL 38mg/dl, Triglycerides 232
EKG: normal sinus rhythm
instructions: Introduction: briefly discuss the purpose of this paper. (no more than 5 sentences)
Assessment: review the provided case study information.
Identify the primary and secondary diagnosis for the patient. Each diagnosis will include the following information:
Plan: (there are five (5) sections to the management plan)
Assessment of Comorbidities: in this section students will review the ADA Standards of Medical Care in Diabetes (the guidelines) Assessment of Comorbidities section on comorbidities subsection and choose one listed comorbidity. Students will discuss the significance of and the relationship between the patient’s primary diagnosis and the chosen comorbidity, explaining how one diagnosis affects the other diagnosis. Any recommended screening, diagnostic testing, and referrals are also included.
Medication costs: in this section students will research the costs of all prescribed and OTC monthly medications that you have prescribed and that the patient is currently taking that you would like to continue. Students may use Good Rx, Epocrates or another resource (students may use local pharmacy websites) which provides medication costs. Students will list each medication, the monthly cost of the medication and the reference source. Students will calculate the monthly cost of the case study patient’s prescribed and OTC medications and provide the total costs of the month’s medications. Reflect on the monthly cost of the medications prescribed. Discuss if prescriptions were adjusted due to cost. Discuss if will you use medication pricing resources in future practice.
RUBRIC:
Assessment: Primary diagnosis
Presentation of the case study patient’s primary diagnosis includes the following required elements:
Diagnosis is consistent with the cited guideline recommendations or scholarly reference, ICD10 code is listed, rationale statement includes a one to two sentence paraphrased pathophysiology statement. The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to the case study patient. Pertinent lab results are included and interpreted within the rationale statement.
Assessment: Secondary diagnosis (es)
Presentation of the case study patient’s secondary diagnosis (es) include (s)the following required elements:
Diagnosis is consistent with the cited guideline recommendations or scholarly reference, ICD10 code is listed, rationale statement includes a one to two sentence paraphrased pathophysiology statement. The rationale statement includes pertinent positive and negative subjective and objective findings from the history and physical exam, which links this diagnosis to the case study patient. Pertinent lab results are included and interpreted within the rationale statement.
Evidence-Based Practice (EBP)
National guidelines are used to support all diagnoses and develop the management plan.
The American Diabetes Association Standards and Medical Care in Diabetes-2019 or later, (or article related to 2019 or later Guidelines) are used to support the primary diagnosis and develop the management plan.
Every diagnosis rationale must include an in-text citation to a scholarly reference as listed in the Reference Guidelines document. Each action step or order within all plan sections includes an in-text citation to an appropriate reference as listed in the Reference Guidelines document. Reference interpretation is accurate.
Plan: Diagnostics
All ordered diagnostics tests are linked to a diagnosis listed in the assessment section and include a paraphrased EBP rationale with citation and include date when test should be performed (ie: today, 1 week, 1 month). Further testing/diagnostics for the differential diagnosis is included. Plans are consistent with the cited guideline recommendations or scholarly reference.
Plan:Medications
The plan includes both prescribed and OTC medications written in prescription format. The plan includes a minimum of one OTC medication. Each prescribed and OTC medication is linked to a diagnosis listed in the assessment section
Diagnosis is clearly stated in the rationale statement. And includes a paraphrased rationale EBP rationale
Plan:Education
All education steps are linked to a diagnosis, paraphrased, and include an EBP rationale.
This section is written exactly how you would discuss the education to the patient. Use vocabulary which the patient can understand, not medical terminology.
Section includes personalized detailed education on diagnoses, medications, diet, exercise and any warning signs. Personalized diet and exercise recommendations are appropriate for the case study patient and include specific instructions for the case study patient such as a specific exercise- length of time to exercise and frequency/week. Any published diet recommendations, such as a Mediterranean diet, will include a rationale statement as to why this recommendation is beneficial for the case study patient.
Plans are consistent with the guideline recommendations or scholarly reference.
Plan:Referrals
All recommended referrals are appropriate for the patient diagnoses:
each referral is linked to a specific diagnosis each which was listed in the assessment section and includes a paraphrased EBP rationale. All referrals related to the primary diagnosis are obtained from the ADA guidelines.
Plans are consistent with the cited guideline recommendations or scholarly reference
Plan: Follow up
Follow up includes a specific time/date to return to PCP office. EBP rationale with in text citation is included. Only follow up information is listed in this section. Additional information, such as future testing, education or referrals are not listed in follow up but within the appropriate paper sections. Plans are EBP and consistent with the guideline recommendations.
Assessment of comorbidities
The ADA guidelines includes a Comprehensive Medical Evaluation and Assessment of Comorbidities section which includes comorbidities that providers should consider when managing disorders of glucose metabolism.
Choose one of the listed comorbidities from the ASSESSMENT OF COMORBIDITIES subsection*
Explain the significance of and the relationship between your primary diagnosis and your chosen comorbidity. Explain how one diagnosis affects the other diagnosis in no more than 3-5 sentences. Include any recommended screening, diagnostic testing, and referrals in no more than 2-3 sentences.
* the chosen comorbidity cannot be any secondary diagnosis already discussed in your paper’s assessment section.
Medication costs
All monthly medication costs are calculated, including the current medications the patient may be already taking.
A total cost for all the month’s medication is included.
All medications including OTCs are included.
Medication cost reference source is included. Summary/reflection statement regarding medication costs and any medications changes based on cost or polypharmacy concerns is included.
ASSIGNMENT FORMAT
Description
Grammar, Syntax, APA
APA format, grammar, spelling, and/or punctuation are accurate, or with zero to one error. All referenced information is cited, “according to” is not used. All cited information is paraphrased, no quotes are included in the paper.
Organization
Paper is developed in a logical, meaningful, and understandable sequence.
Provided assignment template is used to develop the paper. The rationale length does not exceed template directions. The paper length does not exceed 10 pages, excluding title page and references.
In a Microsoft Word document of 5-6 pages formatted in APA style, describe your personal approach to professional nursing practice. Be sure to address each one of the following criteria:
On a separate references page, cite all sources using APA format. Helpful APA guides and resources are available in the South University Online Library. Below are guides that are located in the library and can be accessed and downloaded via the South University Online Citation Resources: APA Style page. The American Psychological Association website also provides detailed guidance on formatting, citations, and references at APA Style.
• APA Citation Helper
• APA Citations Quick Sheet
• APA-Style Formatting Guidelines for a Written Essay
• Basic Essay Template
Please note that the title and reference pages should not be included in the total page count of your paper.
Submission Details:
Hi I need a response for the 2 below soap notes
Peer 1
Patient name: D, V Age: 40 Gender: Female
Chief Complaint:” I have been without menses for 2 months”
HPI: Patient 40 years old female, Hispanic, comes to visit for gynecologic examination, complaining of amenorrhea for 2 months, reports irregular periods before.
Past Medical Hx:
Essential (primary) hypertension I10
Obesity, unspecified E66.9
Hyperlipidemia E78.1
Type 1 Diabetes mellitus with unspecified diabetic retinopathy without macular edema E10.319
Pap smear
Date: 11/17/2018; Notes: HPV negative but reactive cellular changes and/or repair are present, the predominance of coccobacilli consistent with a shift in vaginal flora is present
Date: 11/23/2016; Notes: Normal
Notes: Normal 2008 Negative for Cancer of the ovaries; Asthma; Cancer of the breast; Cancer of the lung; Diabetes; Heart failure, systolic; Heart disease (CAD); Cancer of the colon; Heart failure, diastolic.
Menstrual History
Menstrual information
Notes: Irregular
Pregnancy History
Past pregnancy
Notes: G2 P2 A0 L2
Surgical History
Cesarean section
Social History
Sexually active
Sexually active
Employed
Children
Married
Never smoked
Negative for: Exercise; Past drug use; Alcohol use
Family Hx:
Father: Diabetes mellitus
Mother: Hypertension,
Grandparents: Diabetes mellitus
Allergies: No Know Allergies
Current Medication:
Lisinopril 10 mg tab PO daily.
Glargine 40 units at bedtime
Atorvastatin 80 mg tab PO at bedtime daily
Review of systems
General/Constitutional
Patient t Reports: Amenorrhea for 2 months, she denies chills and night sweats. She also denies weight loss and weight gain or fever.
HEENT
Eyes: Denies swellings, itchiness, blurry vision, discharges. The patient wears glasses.
Head: Denies (pain, vertigo, tinnitus, hoarseness, dysphagia, cough, throat pain, hearing problems, trauma, lump).
Systemic symptoms: Denies (fever, chills). No recently weight loss.
Neurological: Denies sleeping problems, nausea, vomiting, vertigo, weakness, gait change, dizziness, or headache.
Respiratory: Denies cough, shortness of breath, chest pain, cyanosis.
Cardiovascular: Last EKG (atrial fibrillation). The patient denies chest pain, dizziness, SOB, weakness, fatigue, bilateral lower extremity swelling.
Gastrointestinal: Denies abdominal pain, distention, anorexia, diarrheas, nauseas, vomiting, flatulence.
Genitourinary: Pt Reports: Amenorrhea for 2 month, She denies increased urinary frequency, blood in the urine, and nocturia.
Endocrinology: Denies: Excessive appetite; Excessive sweating; Excessive thirst; Excessive urination; Heat/cold intolerance; Hair loss; Excess hair growth
Musculoskeletal: Denies arthralgia, myalgia, or pain to the movement of the joints or muscles cramp.
Integumentary: Denies discomfort and itching in her vagina, denies swollen.
Pt Denies: Skin lump/mass; Mole changes; Performs monthly self-breast exam; Breast lump/mass; Breast pain; Nipple discharge; Stretch marks; Varicose veins; Phlebitis
Neurological: Pt denies Headaches Pt Denies Numbness/tingling; Seizures; Tremors; Difficulty walking; Localized weakness Psychiatric. Pt Denies: Anxiety; Depression; Frequent crying; Nervousness; Hallucinations; Memory loss; Sleep problems; Suicidal thoughts
Hematologic/Lymphatic Pt Denies: Easy bleeding or bruising; Anemia; Swollen glands Allergic/Immunologic
Physical examination
Weight: 172 lbs Temp 98.1 F BP: 132/86 Height 5’2” Pulse:82 Resp: 20
General: The patient is alert and oriented, able to provide accurate information, good eye contact during the interview, cooperative. The patient states a good understanding of the conversation. The patient seems slightly distressed
HEEET Head: Normocephalic, atraumatic, symmetric, no visible or palpable masses, depressions, or scaring. Good hair distribution, good hygiene. No bleeding, no papules, no vesicles.
Neck: Trachea in the midline, No neck veins distention. No posterior cervical adenopathy. No carotid bruits and no goiter.
Ears: TMs (Pale, gray, translucent appearance, Cone of light and bony landmarks visible) & mobile, hearing intact. Ear canals clear without inflammation or redness.
Nose: Smell sense intact, No external or internal lesions observed. No exudate or secretion. No observed septum deviation.
Eyes: Visual acuity intact 20/20 with corrective glasses, Eyes symmetric, no blepharitis, no redness clear conjunctiva, no ocular discharge bilaterally. PERRLA
Throat: Gap reflex present, uvula in the midline, Good hygiene, No lesions in soft tissues, no gingival inflammation, no bleeding. Tonsils 2+
Respiratory: Chest symmetric, Tactile fremitus present. thoracic expansion symmetric. No wheezing or crackles sounds.
Breast: No overlying skin changes; No dimpling; No nipple retraction; No masses or lumps; Right breast no palpable masses or lumps; Left breast no palpable masses or lumps; No tenderness; No regional lymphadenopathy
Additional comments: US-guided biopsy right breast, showing fibroadenoma, no malignancy was seen. Diagnostic mammogram and ultrasound in 1 year are recommended (August 2021)
Skin: Warm to touch, no hyperthermia, Inguinal intertrigo
Cardiovascular: HR regular. No murmur, no thrill, no rubs, No swollen leg. All pulse palpable, no sign of DVT or PAD.
Abdomen: Flat, no tender no distended, No scar visible on inspections, soft on palpation. Liver palpable no splenomegaly, no masses, no pain with palpation. Bowel sound present in all quadrant. The patient denies Costovertebral angle tenderness.
Genitourinary: No erythema, masses, or lesions detected on the external genitalia. The vaginal mucosa is pink. No blood detected on the stool, which is brown. No inguinal adenopathy or adnexal masses noted. No rectovaginal masses detected. Vulva,Vagina,Cervix (Normal appearance); By TV sonogram (Uterus normal size/shape with normal ovaries)
Lymphatic: No visible or palpable adenopathy.
Extremities: Full range of motion in 4 extremities, Pulses present and symmetric. No swelling, no deformities
Neurological: All cranial nerves intact. No weakness, no vertigo, or dizziness. Adequate sensation in 4 extremities. Reflexes are +2
Assessment and Plan
Diagnosis:
Amenorrhea, unspecified N91. Amenorrhea is the absence of menstruation. Secondary amenorrhea occurs when you’ve had at least one menstrual period and you stop menstruating for three months or longer. Secondary amenorrhea is different from primary amenorrhea. It usually occurs if you haven’t had your first menstrual period by age 16.A variety of factors can contribute to this condition, including birth control use, certain medications that treat cancer, psychosis, or schizophrenia, hormone shots, medical conditions such as hypothyroidism, being overweight or underweight
Differential Diagnosis:
Hypothyroidism E03.9: Other clinical signs of thyroid disease are usually noted before amenorrhea presents. Mild hypothyroidism is more often associated with hypermenorrhea or oligomenorrhea than with amenorrhea. Treatment of hypothyroidism should restore menses, but this may take several months.
HYPERGONADOTROPIC HYPOGONADISM E23.0: Ovarian failure can cause menopause or can occur prematurely. On average, menopause occurs at 50 years of age and is caused by ovarian follicle depletion. Premature ovarian failure is characterized by amenorrhea, hypoestrogenism, and increased gonadotropin levels occurring before 40 years of age and is not always irreversible (0.1 percent of women are affected by 30 years of age and one percent by 40 years of age). Approximately 50 percent of women with premature ovarian failure have intermittent ovarian functioning with a 5 to 10 percent chance of achieving natural conception
Polycystic ovary syndrome (PCOS) E 28.2: is a hormonal disorder common among women of reproductive age. Women with PCOS may have infrequent or prolonged menstrual periods or excess male hormone (androgen) levels. The ovaries may develop numerous small collections of fluid (follicles) and fail to regularly release eggs.
The exact cause of PCOS is unknown. Early diagnosis and treatment along with weight loss may reduce the risk of long-term complications such as type 2 diabetes and heart disease.
PLAN
Further Testing:
Pregnancy test. This will probably be the first test your doctor suggests, to rule out or confirm a possible pregnancy.
Thyroid function test. Measuring the amount of thyroid-stimulating hormone (TSH) in your blood can determine if your thyroid is working properly.
Ovary function test. Measuring the amount of follicle-stimulating hormone (FSH) in your blood can determine if your ovaries are working properly.
Prolactin test. Low levels of the hormone prolactin may be a sign of a pituitary gland tumor.
Transvaginal ultrasound.
Medication: Treatment depends on the underlying cause of your amenorrhea. In some cases, contraceptive pills or other hormone therapies can restart your menstrual cycles. Amenorrhea caused by thyroid or pituitary disorders may be treated with medications. If a tumor or structural blockage is causing the problem, surgery may be necessary.
Education: Some lifestyle factors such as too much exercise or too little food can cause amenorrhea, so strive for balance in work, recreation, and rest. Assess areas of stress and conflict in your life. If you cannot decrease stress on your own, ask for help from family, friends or your doctor.
Be aware of changes in your menstrual cycle and check with your doctor if you have concerns. Keep a record of when your periods occur. Note the date your period starts, how long it lasts and any troublesome symptoms you experience.
Return to office: The patient should return to the clinic immediately if the condition worsens and symptoms persist. Follow-up should be done in two weeks if the condition does not worsen.
References
DeCherney AH, et al. Current Diagnosis & Treatment Obstetrics & Gynecology.11th ed. New York, N.Y.: The McGraw-Hill Companies; 2013. http://www.accessmedicine.com/resourceTOC.aspx?resourceID=788. Accessed Jan. 21, 2014.
Klein DA, et al. Amenorrhea: An approach to diagnosis and management. American Family Physician. 2013;87:781.
Goldman L, et al. Goldman’s Cecil Medicine. 24th ed. Philadelphia, Pa.: Saunders Elsevier; 2012. http://www.clinicalkey.com. Accessed Jan. 20, 2014.
Reply
Patient Information:
Name: KG
Age: 23 y/o.
Gender: Female.
Race: Hispanic
Advanced Directives: Full Code
Source: Patient
Past medical History
Chronic Illnesses/Major traumas: Obesity.
Family Medical History: Mother diagnosed with: Diabetes Mellitus Type 2, 45 y/o, alive.
Father diagnosed with: Gout, 50 y/o, alive.
Allergies: None.
Surgery: None
Screening Hx/Immunizations Hx: TT, 2020. Flu: 2020, Pap smear 2020 (Negative)
Current Medications:
-Tylenol 500 mg 1tab PO every 6 hours for mild pain/fever
Social history: Patient has high school degree, and she works at a mall for 5 years. She is single and she is sexually active and has history of unprotected vaginal sex with multiple partners. Actually, she lives with her son and her parents, he is 5 years old. The support is her family and denies any needs at this time. She has adequate shelter. She has a sedentary life. She doesn’t have healthy diet. She denies substance abuse, ETOH, tobacco, marijuana or illicit drug ingestion.
Subjective:
CC: “I had been with foul-smelling vaginal discharged, pain during urination and bleeding after having sex for the last 2 weeks without relief.”
HPI: This is a 23-yr. old Hispanic, female who goes to the clinic with c/o foul-smelling vaginal discharged, dysuria, dyspareunia and bleeding after coitus for the last 2 weeks without relief. Patient denied fever or previous vaginal malodorous. She is sexually active and reports multiple sexual partners, a history of negative result of Papanicolaou tests in the recent past, and recent unprotected vaginal intercourse. She claims poor pain relief with Tylenol 500 mg oral every 6 hours. Also, she denies history of sexually transmitted disease, douching and antibiotic use recently. She informs the vaginal discharge looks like creamy greenish and has foul-smelling odor. She mentions that she feels a sharp pain in the lower abdomen which she rates a 3 out of 10. She refers mild distress related to painful sexual intercourse. Denies abdominal trauma, fatigue, vomit, nausea and diarrhea. She does not present any past medical history. She has not had similar symptoms in the past. The menarche was at 12 y/o, the LMP: 10/5/2020 for 6 days, regular cycle, plus the spots already described, G1T1P1A0L1.
ROS:
General: She refers weight gain 10 pounds in the last month, denies fatigue, fever, malaise and decreased energy level.
Skin: She denies healing problems, rashes, bruising, bleeding or skin discolorations, no changes in lesions. She has a mole (birthmark) in her left side of her neck.
Eyes: She denies changes in her vision, diplopia, blurry vision, no redness or swelling, watering or discharge.
Ears: She denies hearing loss, ear pain, ringing in ears, discharge.
Nose/Mouth/Throat: She denies runny nose, epistaxis, hoarseness, dysphagia, sinus problems, or discharge, no dental disease, and no throat pain.
Breast: Refers to do SBE every month, denies lumps, bumps or changes.
Heme/Lymph/Endo: She denies bruising or bleeding, purpura, petechiae, prolonged or excessive bleeding, no blood transfusion and HIV Hx, night sweats, swollen glands, no increase thirst, increase hunger, cold or heat intolerance.
Cardiovascular: She denies palpitations, orthopnea, chest pain, and no edema.
Respiratory: She denies cough, wheezing, and dyspnea at this moment.
Gastrointestinal: She denies nausea, vomiting, diarrhea, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools, and no abdominal pain. Denies colonoscopy.
Genitourinary/Gynecological: She complains of creamy greenish vaginal discharge accompanied with dyspareunia, and vulvar burning, especially when she urinates, sharp pain in the lower abdomen which she rates a 3 out of 10, 4 days ago. The menarche was at 12 y/o, the LMP: 10/5/2020 for 6 days, regular cycle, plus the spots already described, G1T1P0A0L1. Last Pap smear at 2020 was negative.
Musculoskeletal: She denies any limitation in movements in upper or lower extremities. No other joint pain, stiffness, swelling, or muscle plain.
Neurological: She denies seizures, transient paralysis, weakness, black out spells, and no syncope. She refers paresthesia in bilateral lower extremities.
Psychiatric: She denies any changes of behavior, depression, sleeping difficulties, suicidal ideation/attempts. She refers mild distress related to painful sexual intercourse.
Objective:
Physical Exam:
GENERAL: Patient is obese, no acute distress, maintain adequate hygiene. Patient is alert and oriented and answers questions appropriately. She is very cooperative and maintain good eyes contact.
Vital signs:
Temperature: 97.5 F
RR: 18 x min
HR: 73 x min
O2Sat: 98 %;
Blood Pressure: 130/75 mmhg
BMI: 32.9
Weight: 180 pounds. Height: 5.2”.
Pain scale: 3/10.
Skin: The skin is white, warm, dry, clean, pink, and intact. No noted rashes, no open wounds. Noted a mole 1/3 superior of left side of the back, light brown, irregular shape, flat, 7 inches, not painful, not itching, no changes in color.
HEENT
Head: Normocephalic, no deformities and midline. Hair is clean, thick, soft, and curly and well distributed on the head. Scalp is clean, dry, and without lesions.
Eyes: Symmetrical, pupils’ equal round and reactive to light and accommodation, red reflex noted and light reflected symmetrically bilaterally, visual field full by accommodation. No conjunctival or scleral injection. She wears corrective lenses.
Ears: TM is pearly gray and translucent, bony landmarks, and light reflex noted bilaterally. Canals patent. No lesion noted.
Nose: External nose is smooth and symmetrical, firm/stable structure noted, mucosa/turbinates deep pink, moist, glistening. No septal deviation.
Throat: Posterior pharyngeal wall is moist, glistening, non/reddened, without exudate, Tonsils are 1+, bilaterally.
Neck: Symmetric. Noted Full ROM, no cervical lymphadenopathy, no occipital nodes. No thyromegaly or nodules.
Oral mucosa: Pink and moist. Pharynx is non erythematous and without exudate. Teeth are in good repair.
Cardiovascular
Heart: Upon auscultation S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs nor murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.
Respiratory
Chest: Symmetric. Lungs are clear bilaterally anterior/posterior, no wheezing, no rhonchi, no adventitious breath sounds.
Gastrointestinal: Abdomen flat, no deformities; BS active in all 4 quadrants, mild diffuse lower abdominal tenderness on deep palpation. No hepatosplenomegaly.
Breast: No tender, no deformities, no lumps or mases noted.
Genitourinary: Bladder is non-distended; no CVA tenderness.
External genitalia reveal coarse pubic hair is well distribution; skin color is consistent with general pigmentation. Noted an erythematous area in the upper third of the vulva, near the urethra. Well estrogenized. A small speculum was inserted; vaginal walls are covered by purulent exudate and bleeding. Upon detaching them from the base, an erythematous area is left. Cervix is erythematous with punctate hemorrhages (strawberry-patch cervix), also friability noted and multiparous. Scant purulent and cloudy drainage present. On bimanual exam, cervix is firm, cervical motion tenderness is also present. Uterus is normal size, minimally tender, antevert and positioned behind a slightly distended bladder. Rectovaginal exam reveals uterosacral nodularity and exquisite tenderness. Stool is soft, brown and heme-negative. Ovaries are nonpalpable.
Heme/Lymph/Endo: Upon palpation no lymphadenopathy and organomegaly noted.
Musculoskeletal: Symmetric, full ROM in all extremities. Extremities are warm without edema.
Neurological: Patient is A, A, OX 4. Speech clear, maintain good tone. Posture is erect. The balance is stable and the gait is rhythmical, flowing, effortless, with freely swinging legs and with an upright body posture.
Psychiatric: She is alert and oriented X 4. She is dressed in a clean dress and coat. She maintains eye contact. Her speech is soft, and clear, answers questions appropriately.
Lab Tests
• NAAT: It is positive for Chlamydia trachomatis or Neisseria gonorrhoeae: Still pending the result.
• Urine culture and sensitivity: Still pending the result.
• Wet mount examination of cervical discharge: Sensitive indicator of cervical inflammation, in the absence of inflammatory vaginitis. Microscopy is only 50% sensitive for detection of Trichomonas vaginalis, whereas culture is the most sensitive test. Bacterial vaginosis may be diagnosed by presence of at least 3 of the 4 Amsel criteria: 1) adherent white vaginal discharge; 2) clue cells on microscopy (vaginal epithelial cells with distinctive stippled appearance as covered by bacteria); 3) vaginal pH >4.5; 4) “whiff test” (release of fishy odor following addition of 10% potassium hydroxide solution). Result shows>10 WBCs per high-power field of vaginal fluid (leukorrhea), trichomonads, clue cells, pH: 5, fishy amine odor with application of 10% KOH.
• HIV test: Negative.
• Rapid tests (OSOM Trichomonas, AFFIRM VPIII): Fast and reliable point of care tests with sensitivity >83%, specificity >97%. Results available within 10 minutes for OSOM Trichomonas rapid test and in 45 minutes for AFFIRM VP III. Result is positive for Trichomonas vaginalis
• Gram stain of cervical discharge: For diagnosis of bacterial vaginosis. Nugent score is used, which involves counting bacterial morphocytes. Possible result reveals Lactobacillus morphotype reduced or absent. Still pending the result.
• Thayer-Martin agar cervical culture: For detection of N gonorrhoeae. Possible result reveals growth of pathogen. Still pending the result.
• Pregnancy test: It is important to determine if patient is not pregnant to provide her the appropriate treatment, avoid the teratogenesis (Jameson et al., 2020). It was negative.
Special Tests: None
Primary Diagnosis
A: The primary diagnosis for the patient is: Cervicitis (N72): Cervicitis is common and often asymptomatic, but if left undiagnosed or untreated can result in pelvic inflammatory disease, which can lead to substantial long-term ill effects such as infertility and chronic pelvic pain. Implementing screening protocols for high-risk populations may reduce adverse outcomes from cervicitis. Screening for other sexually transmitted infections (STIs) should be offered concomitantly. While Neisseria gonorrhoeae and Chlamydia trachomatis are the most commonly isolated organisms, in most cases no organism is identified. Clinical suspicion is generally sufficient to justify therapy, but of the diagnostic aids, nucleic acid amplification testing remains the most sensitive and specific tool for accurately diagnosing N gonorrhoeae and C trachomatis. If the presentation suggests cervicitis, and the patient is deemed at high risk for STI, patients are empirically treated with a regimen targeting STIs. There are some risk factors to develop the disease such as women of reproductive age (15 to 29 years old), prior history of STI, inconsistent condom uses and multiple sexual relationships (Jameson et al., 2020).
In this patient, we can find some signs and symptoms such as: her c/o foul-smelling vaginal discharged, dysuria, dyspareunia and bleeding after coitus for the last 3 weeks without relief. Patient denied fever or previous vaginal malodorous. She is sexually active and reports multiple sexual partners, a history of negative result of Papanicolaou tests in the recent past, and recent unprotected vaginal intercourse. She claims poor pain relief with Tylenol 500 mg oral every 6 hours. Also, she denies history of sexually transmitted disease, douching and antibiotic use recently. She informs the vaginal discharge looks like creamy greenish and has foul-smelling odor. She mentions that she feels a sharp pain in the lower abdomen which she rates a 3 out of 10. She refers mild distress related to painful sexual intercourse. Also, physical examination reveals vaginal walls are covered by purulent exudate and bleeding. Upon detaching them from the base, an erythematous area is left. Cervix is erythematous with punctate hemorrhages (strawberry-patch cervix), also friability noted and multiparous. Scant purulent and cloudy purulent and cloudy drainage present.
On bimanual exam, cervix is firm, cervical motion tenderness is also present. The patient presents some risk factors to develop the disease such as women of reproductive age (15 to 29 years old), multiple sexual relationships and inconsistent condom uses.
Secondary Diagnosis:
Secondary Diagnosis:
Differential Diagnoses
PLAN:
Med/Meds:
Symptomatic treatment:
Treatments:
Diagnostic:
• NAAT
• Urine culture and sensitivity
• Wet mount examination of cervical discharge
• HIV test
• Rapid tests (OSOM Trichomonas, AFFIRM VPIII
• Gram stain of cervical discharge
• Thayer-Martin agar cervical culture
• Pregnancy test
Procedures performed: None
Education: Patient was instructed to:
• Promote the monogamy (or at least a reduction in the number of partners)
• Encourage the use of male condoms may help prevent spread of infection.
• Educate about the importance of completing the treatment and side effects of medication.
• Encourage follow up diagnostic test to obtain an accurate and effective treatment.
• Abstain from sex until the symptoms completely heal.
• Advised her sexual partners to go to a clinic for evaluation as there are high chances that they are infected too.
• Observe hygiene and sanitation to ensure that the symptoms such as irritation and swelling improve.
• Advised for external dysuria may also be alleviated by urinating with the genitals submerged in water.
• Encourage that if these symptoms do not improve in the next week of treatment, for her to come back to the clinic for more evaluation.
• Avoid use of fabric softeners, harsh soap, nylon or synthetic underwear.
• Encourage the importance to maintain hand hygiene, diet habits and lifestyle modification such as increase physical activity.
• Educate about cervical cancer screening should begin approximately 3 years after a woman begins having vaginal inter- course, but no later than 21 years of age. Screening should be done every year with conventional Pap tests or every 2 years using liquid-based Pap tests (Burns et al., 2017).
Referrals: None
Follow-up: Pt is advised to follow-up in 7 days. If symptoms persist or worsen call or make an appt. Questions were answered to patient’s satisfaction.
Peer 2
DEMOGRAPHIC INFORMATION
Name: Mrs. M.E.
Age: 47-year-old
Race: Hispanic.
Insurance: Medicaid.
Advance directives: yes, since 04/25/2020.
Subjective Data:
CHIEF COMPLAIN: “I have been having hot flashes for the past few months”.
HISTORY OF PRESENT ILLNESS: Mrs. ME is 47 y/o female, Hispanic, she states in our office today because she has been having hot flashes for the past few months. Patient reports experiencing two or three hot flashes per day. Mrs. ME also reports she is awakened from sleep, soaked by night sweats. Her symptoms began seven months ago, and over that time, they have worsened to the point where have become very bothersome. She is worried because she cannot remember the date of her las period; but she’s sure she does not see her period several months ago. Patient denies headache, fever, change in appetite or weight.
PAST MEDICAL HISTORY: Denies past medical history
SURGICAL PROCEDURES: T and A as a child
OB/GYN HISTORY: G1 T1 P0 A0 L1
HOME MEDICATIONS: Centrum Women PO Daily Vitamin C (500mg) PO Daily ALLERGIES: NKA VACINATIONS: Immun
N1. Discuss the different types of micronutrients and their function in the body. Choose two micronutrients and discuss the signs and symptoms of toxicity and deficiency for each nutrient. What disease process would cause toxicity and deficiencies for both nutrients? Use evidence from one scholarly source other than your textbook or ATI book to support your answer. Use APA Style to cite your source.
-uploading the textbook pdf as one source need at least 2 more.
2. Respond to case study below too.
Tonya is 5′ 3″ tall, weighs 151 pounds, and is 38 years old. Her waist circumference is 37″. Her life is busy but sedentary. She simply does not have the time or energy to stay with an exercise program after working all day as a receptionists and caring for her two socially active children. She would like to lose about 20 pounds but knows dieting doesn’t work for her—all the diets she has tried in the past have left her hungry and feeling deprived. Losing weight has taken on greater importance since her doctor told her that both her blood pressure and glucose levels are at “borderline” high levels.
Attention Wizard Kim.
Week 6 Discussion: Practicum professional Development Objectives/ Progress Appraisal 3 pages.
Rubrics
