Tag: Clinical-Nursing

Primary Diagnosis with ICD-10 Code Management Plan Nursing Essay

Management Plan

Primary Diagnosis with ICD-10 Code

Primary Diagnosis:
Hypertension, primary (essential)
ICD-10 Code:
I10

The patient’s elevated blood pressure readings in both arms (172/94 and 178/98) and associated symptoms of headache, tiredness, and sleep disturbances due to snoring indicate hypertension as the primary diagnosis. Hypertension, according to Iqbal and Jamal (2019), is a widespread condition and a substantial risk factor for cardiovascular disease. These include heart attacks and strokes. The patient’s BMI of 28.7 and poor diet are also contributory factors.

BUY A PLAGIARISM-FREE ASSIGNMENT HERE

CPT Code for Initial Evaluation:
99204 (Comprehensive new patient office visit)

Nurse Lab Draws:
CMP (Comprehensive Metabolic Panel) and Lipid Panel

Vaccinations Given:
Ensure the patient is up to date on recommended vaccinations, including influenza and pneumococcal vaccines.

Guidelines Used to Develop This Primary Diagnosis

The diagnosis of primary hypertension is based on the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-8) guidelines. These guidelines define hypertension as blood pressure greater than 130/80 mm Hg (Banga et al., 2019).

Differential Diagnoses with Rationale and Resources

Hypertension, secondary:
 Secondary hypertension may be considered if the primary diagnosis does not respond adequately to treatment. It may also be considered if additional symptoms and history suggest an underlying cause like renal disease or endocrine disorders (Ruaro et al., 2022).

Hypertension, white coat/pseudoresistant:
 White coat hypertension is possible if the patient’s elevated blood pressure readings are only observed in clinical settings but not in other environments. Ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring can help rule out this diagnosis.

Obstructive Sleep Apnea:
 Given the patient’s report of snoring and sleep disturbances, obstructive sleep apnea should be considered a differential diagnosis (Gottlieb & Punjabi, 2020). Polysomnography (sleep study) may be needed to confirm this condition.Primary Diagnosis with ICD-10 Code management plan Nursing Essay

Medications, Dosage, Education, Additional Ancillary Tests, Referrals, and Follow-Up

Medications:
Initiate antihypertensive therapy with consideration of lifestyle modifications.

Medication:
ACE inhibitor (Lisinopril)

Dosage:
Start with Lisinopril 10 mg daily, titrate as needed based on blood pressure response.

Education:
Educate the patient about the necessity of drug adherence, possible adverse effects, and the necessity for periodic follow-up sessions.

Additional Ancillary Tests:

Ambulatory Blood Pressure Monitoring (ABPM):
To confirm the diagnosis and assess for white coat hypertension.

Polysomnography:
If obstructive sleep apnea is strongly suspected based on symptoms.

Referrals:

Cardiologist:
Refer the patient to a cardiologist for further evaluation and management of hypertension.

Sleep Specialist:
If obstructive sleep apnea is diagnosed or strongly suspected.

Follow-Up:
Arrange a follow-up session in 2-4 weeks to examine the patient’s reaction to treatment and, if required, alter prescriptions.

Problem Statement

The patient, a 57-year-old Hispanic individual, presents with high blood pressure, associated symptoms of headache, tiredness, sleep disturbances due to snoring, and a 10-pound weight gain over the last year. Primary Diagnosis with ICD-10 Code management plan Nursing Essay The BMI is 28.7, indicating overweight, and the patient reports a poor diet. Physical examination reveals elevated blood pressure readings in both arms, laterally displaced PMI, and prominent arteriovenous (AV) nicking with a 3:1 ratio. The primary concern is managing primary hypertension and assessing potential secondary causes or comorbid conditions.

Social Determinants of Health, Health Promotion, and Patient Risk Factors

Social Determinants of Health:
 Assess the patient’s socioeconomic status, living conditions, access to healthcare, and support system. Address any identified barriers to medication adherence and lifestyle modifications.

Health Promotion:
Emphasize the importance of lifestyle modifications. These include dietary changes, regular physical activity, and weight management Primary Diagnosis with ICD-10 Code management plan Nursing Essay.

Patient Risk Factors:
 Recognize the risk factors, like ethnicity and family history of hypertension. Provide education on risk reduction strategies, including smoking cessation if applicable.

 

References

Banga, S., Mungee, S., Patel, A. R., Singh, S., Kizhakekuttu, T. J., & Kizhakekuttu, T. (2019). Management of resistant hypertension based on recommendations from different guidelines and the systolic blood pressure intervention trial. Cureus, 11(8).
https://doi.org/10.7759/cureus.5371

Gottlieb, D. J., & Punjabi, N. M. (2020). Diagnosis and management of obstructive sleep apnea: a review. 
Jama
, 
323
(14), 1389-1400.
https://doi.org/10.1001/jama.2020.3514

Iqbal, A. M., & Jamal, S. F. (2019). Essential hypertension.

Ruaro, B., Salton, F., Baratella, E., Confalonieri, P., Geri, P., Pozzan, R., … & Hughes, M. (2022). An overview of different techniques for improving the treatment of pulmonary hypertension secondary in systemic sclerosis patients. Diagnostics, 12(3), 616.
https://doi.org/10.3390/diagnostics12030616
  Primary Diagnosis with ICD-10 Code management plan Nursing Essay

NRNP-6540 Week 9: Knowledge Check Quiz ENDOCRINE, METABOLIC, AND NUTRITIONAL DISORDERS

Question 1

1 
/ 1
 pts

Which of the following BMI choices would be considered obesity?

BMI 21 or greater

 

BMI 24 or greater

 

Correct!

BMI 30 or greater

 

BMI 34 or greater

 

ORDER QUIZZES, EXAMS OR ASSIGNMENTS HERE

Question 2

1 
/ 1
 pts

The NP recognizes that all of the following patients have an increased risk of developing adverse effects from metformin (Glucophage) except:

 

Patients who drink lots of alcohol

 

Patients who are dehydrated

 

Patients with renal disease

 

Correct!

Patients who are overweight

 

Metformin (Glucophage) often causes weight loss. Metformin may rarely cause a serious, life threatening condition called lactic acidosis. Patients with dehydration, renal disease, and alcoholism, especially binge drinking, increased their risk for developing lactic acidosis.

NRNP-6540 Week 9: Knowledge Check Quiz ENDOCRINE, METABOLIC, AND NUTRITIONAL DISORDERS Question 3

1 
/ 1
 pts

 Stefanie is a 70 y/o female with 2 year history of Type II  diabetes, presents to your office for her routine follow up visit. Which of the following would you recommend on an annual basis for an elderly patient with Type II Diabetes?

 

Correct!

An eye examination with an ophthalmologist

 

Ankle brachial index

 

Colonoscopy

 

Bone density scan

 

Patients with Type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist shortly after the diagnosis of diabetes. Subsequent examinations for Type 1 and Type 2 Diabetic patients should be repeated annually by an ophthalmologist. Examinations will be required more frequently if retinopathy is progressing. 

Question 4

1 
/ 1
 pts

The NP is reviewing annual labs on a patient with Type II diabetes.  The urine glucose level is over 200.  What medication would the NP suspect that patient is taking?

Metformin

 

Correct!

Empagliflozin

 

Ozempic

 

Glyburide

 

Question 5

1
/ 1
 pts

A 66-year-old male patient who has hypothyroidism takes level thyroxine daily. Based on the following lab results, how should the nurse practitioner proceed?

TSH

28.2 mIU/L

Normal Values:

0.4-3.8 mIU/L

Free T4

0.05 ng/dL

Normal Values:

0.8-2.8 ng/dL

 

Total Cholesterol

272 mg/dL

Normal Values:

<200 mg/dl LDL Cholesterol 189 mg/dL Normal Values: <100 HDL Cholesterol 34 mg/dL Normal Values: 40-60 Triglycerides 142 mg/dL Normal Values: <150 Begin statin therapy   Encourage diet modifications   Encourage lifestyle modifications   Correct! Adjust levothyroxine dose   Dyslipidemia is a common finding when TSH values exceed 10 mIU/L. In patients who have hypothyroidism, there is decreased catabolism of LDL, primarily due to a reduction of cell surface receptors for LDL. This causes an accumulation of LDL cholesterol. The NP should first treat the TSH to 10 mIU/L or less. Lipids should be treated if they remain elevated after TSH is less than 10 mIU/L. NRNP-6540 Week 9: Knowledge Check Quiz ENDOCRINE, METABOLIC, AND NUTRITIONAL DISORDERS Question 6 1  / 1  pts The most appropriate time to begin screening for renal nephropathy in a patient with Type I Diabetes is: Two to three years after diagnosis   At diagnosis   Once annually after diagnosis   Correct! Five years after diagnosis   Patients with Type I Diabetes should be screened for renal nephropathy five years after diagnosis. Since nephropathy takes several years to develop, it is highly improbable that a newly diagnosed patient will have no properties secondary to diabetes. Diabetic nephropathy is usually diagnosed based on the presence of albuminuria and/or reduced eGFR in the absence of signs or symptoms of other primary causes of kidney damage. Question 7 1  / 1  pts Identify the lab findings consistent with primary hypothyroidism Correct! Elevated thyroid stimulating hormone and decreased T4 level   Decreased thyroid stimulating hormone and elevated free thyroxine level   Elevated thyroid stimulating hormone and elevated free T4 level   Decreased thyroid stimulating hormone and low free T4   Question 8 1 / 1  pts According to the clinical practice guideline by the American Association of Clinical Endocrinology, the NP should consider initiating insulin therapy when the HgA1c reaches what level? Greater than 8   Greater than 9   Correct! Greater than 10   Greater than 11   Question 9 1  / 1  pts A 70-year-old male is seen for his annual evaluation.   The patient completins of episodes of blurred vision but denies pain and photophobis.    During funduscopic examination, the nurse practitioner appreciates retinal drusen. This presentation is consistent with Cataracts   Glaucoma   Herpes opthalmicus   Correct! Macular degeneration   Macular degeneration is typically characterized by loss of central vision. Early complaints and findings include patchy or blurry vision and the presence of retinal drusen, pale yellow deposits visible upon ophthalmic examination.  Question 10 1  / 1  pts Mrs Thompson presents today with concerns of functional decline, progressive appetite loss, and no willingness to eat or drink. The  NP recognizes that these are symptoms of: Correct! Adult failure to thrive   Hashimotos thyroiditis   Acute pancreatitis   None of the above as this is a normal part of aging   Miss Johnson’s symptoms are consistent with adult failure to thrive. It is important that the NP recognizes that this is not a normal part of aging and it should be assessed properly. NRNP-6540 Week 9: Knowledge Check Quiz ENDOCRINE, METABOLIC, AND NUTRITIONAL DISORDERS

Riku Organization and Control of Neural Function Case Study

Riku is a 19-year-old college student. One morning, after a long night of studying, Riku woke up and made himself a hot cup of coffee and toast. Much to his surprise, when he brought the cup to his mouth to drink, the coffee spilt onto the table. Riku went to the bathroom mirror and noticed the left side of his face seemed to droop. He quickly got dressed and ran to the medical clinic on the college campus. As he ran, his left eye began to feel scratchy and dry, but he could not blink in response. The physician at the clinic listened to Riku’s story and then did a careful cranial nerve examination. She concluded that Riku had Bell palsy, an inflammatory condition of the facial nerve most likely caused by a virus. Student Name: What are an afferent neuron and efferent neuron? What are efferent components of the facial nerve and their actions? Under certain circumstances, axons in the peripheral nervous system can regenerate after sustaining damage. Why is axonal regeneration in the central nervous system much less likely? At a healthy myoneural junction, acetylcholine is responsible for stimulating muscle activity. Riku Organization and Control of Neural Function Case Study What mechanisms are in place to prevent the continuous stimulation of a muscle fiber after the neurotransmitter is released from the presynaptic membrane?

BUY A PLAGIARISM-FREE ESSAY HERE

Introduction

The case study involves a 19-year-old college student who woke up with the left side of his face drooping after a long night of studying. On his way to the medical clinic, his left eye began to feel scratchy and dry, and he could not blink. The physician conducted a cranial nerve examination and found that the patient had bell palsy, which presents with weaknesses or paralysis of facial muscle mainly caused by a virus leading to inflammation or damage of the cranial nerve VII (facial nerve). This paper will discuss differences between afferent and efferent neurons, efferent components of the facial nerve, axonal degeneration in the central nervous system, and mechanisms preventing continuous muscle fiber stimulation at a healthy myoneural junction.

Afferent Neuron and Efferent Neuron

Afferent neurons transmit sensory information from sensory organs like skin, eyes, and ears to the central nervous system (CNS) (Aragona et al., 2022). They detect stimuli like touch, pain, and temperature and transmit these signals to the brain and spinal cord for processing. As the patient was on his way to the medical clinic, his temperature rose, and he encountered some light detected by the sensory neutrons converting these stimuli into nerve impulses that the CNS, which, after processing, he could not blink. Afferent neurons help us perceive and become aware of our external environment and internal bodily conditions Riku Organization and Control of Neural Function Case Study.

Efferent neurons transmit signals from the central nervous system (CNS) to effector organs, such as muscles (Yam et al.,2018). These neurons initiate and control muscle contractions and glandular secretions. Efferent neurons are responsible for carrying out motor commands, including voluntary movements. They carry out commands and instructions from the CNS to initiate specific actions. Efferent neurons control voluntary muscle movements, involuntary muscle actions like heart rate and digestion, and the release of hormones and other substances by glands (Norris & Lalchandani, 2018). They execute the body’s responses to sensory input and maintain various physiological functions.

Efferent Components of the Facial Nerve and Their Actions

The facial nerve (cranial nerve VII) has several efferent components that control various facial muscles responsible for facial expressions and some glands. The facial nerve controls the muscles responsible for facial expressions, including the orbicularis oculi, which closes the eyelids; the orbicularis iris, responsible for closing the lips; and other facial muscles involved in smiling, frowning, and other expressions (Norris & Lalchandani, 2018). His orbicularis oculi were affected since he could not blink. Salivary Glands also innervate the submandibular and sublingual salivary glands, stimulating saliva production.

Axonal Regeneration in the Peripheral vs. Central Nervous System

Due to several factors, axonal regeneration is much more likely in the peripheral nervous system (PNS) than in the central nervous system (CNS) (Norris & Lalchandani, 2018). The environment within the CNS is inhibitory to axonal regeneration. After an injury, glial cells called oligodendrocytes in the CNS release inhibitory molecules like myelin-associated glycoproteins and chondroitin sulfate proteoglycans, which create physical and chemical barriers that impede axon growth (Norris & Lalchandani, 2018). In the PNS, Schwann cells are crucial in supporting axonal regeneration. They provide physical guidance for regenerating axons and release growth-promoting factors. The equivalent glial cells in the CNS are oligodendrocytes, which do not have the same regenerative properties as Schwann cells. Neurons in the CNS generally have a lower intrinsic regenerative capacity than those in the PNS. This intrinsic regenerative capacity refers to the neuron’s ability to initiate and sustain axonal growth.

In response to CNS injury, astrocytes in the CNS tend to form scar tissue. This glial scar further inhibits axonal regeneration by creating a physical barrier and releasing inhibitory factors. The CNS contains highly complex neural circuits with precise connections. Even if axonal regeneration were possible, ensuring that regenerated axons connect correctly and functionally reestablish the lost neural pathways would be challenging. This level of precision is much more challenging in the CNS than in the simpler PNS. The CNS has a limited neuronal plasticity and reorganization capacity compared to the PNS. This means that even if axons can regenerate, the CNS may not be able to adapt and rewire effectively to restore lost functions. The window of opportunity for successful axonal regeneration in the CNS is often limited. After injury, the damaged tissue undergoes significant changes, making it increasingly difficult for axons to regenerate effectively (Norris & Lalchandani, 2018).

Preventing Continuous Stimulation of Muscle Fibers at Myoneural Junction

Several mechanisms in a healthy myoneural junction, also known as a neuromuscular junction, prevent muscle fibers’ continuous stimulation after acetylcholine (ACh) is released from the presynaptic membrane (Norris & Lalchandani, 2018). This is crucial to ensure that muscle contractions are precisely controlled and do not become uncontrollable Riku Organization and Control of Neural Function Case Study.

Acetylcholinesterase, an enzyme in the synaptic cleft (the gap between the motor neuron’s presynaptic membrane and the muscle fiber’s postsynaptic membrane), rapidly breaks down acetylcholine into its constituent parts, acetic acid and choline (Kaur et al., 2019). This breakdown process is highly efficient and occurs within milliseconds of ACh release. By degrading ACh, acetylcholinesterase ensures that ACh’s stimulatory effect on the muscle fiber is short-lived. After acetylcholinesterase breaks down ACh into choline and acetic acid, choline is actively transported back into the presynaptic neuron. This process helps recycle choline for the synthesis of new acetylcholine molecules. This recycling limits the availability of choline for ACh synthesis and release, contributing to the termination of muscle stimulation.

The postsynaptic membrane of the muscle fiber contains ACh receptors. When ACh binds to these receptors, it triggers muscle fiber depolarization and contraction (Norris & Lalchandani, 2018). However, with continuous ACh binding, these receptors undergo desensitization. This means that they become less responsive to ACh stimulation, reducing the effectiveness of ACh in stimulating the muscle fiber. The action potential (electrical signal) that travels along the motor neuron has a limited duration. Once the action potential ends, ACh release from the presynaptic membrane also ceases. This ensures that the stimulus for muscle contraction is transient and does not persist indefinitely.

Calcium ions play a crucial role in muscle contraction. The release of ACh from the motor neuron causes an influx of calcium ions into the muscle fiber’s cytoplasm. However, the sarcolemma, muscle cell membrane, and the sarcoplasmic reticulum, an organelle within muscle cells, actively regulate calcium levels (Norris & Lalchandani, 2018). Once the stimulus ends, the sarcoplasmic reticulum takes up calcium ions, reducing their concentration in the cytoplasm and allowing the muscle fiber to relax.

 

References

Aragona, M., Porcino, C., Guerrera, M. C., Montalbano, G., Laurà, R., Cometa, M., … & Germanà, A. (2022). The BDNF/TrkB neurotrophin system in the sensory organs of zebrafish. 
International Journal of Molecular Sciences
, 
23
(5), 2621.
https://doi.org/10.3390/ijms23052621

Kaur, A., Anand, C., Singh, T. G., Dhiman, S., & Babbar, R. (2019). Acetylcholinesterase inhibitors: A milestone to treat neurological disorders. 
Plant Arch
, 
19
, 1347-1359.

Norris, T. L., & Lalchandani, R. (2018). 
Porth’s pathophysiology: Concepts of altered health states
. Lippincott Williams & Wilkins Riku Organization and Control of Neural Function Case Study.

Yam, M. F., Loh, Y. C., Tan, C. S., Khadijah Adam, S., Abdul Manan, N., & Basir, R. (2018). General pathways of pain sensation and the major neurotransmitters involved in pain regulation. 
International Journal of Molecular Sciences
, 
19
(8), 2164.
https://doi.org/10.3390%2Fijms19082164

NRNP-6540 week 7 KNOWLEDGE CHECK: ABDOMINAL, UROLOGICAL, AND GYNECOLOGICAL DISORDERS

Question 1

1
/ 1
 pts

A 74-year-old patient presents with cramping abdominal pain, nausea, and vomiting for 4 days.  All of the following are potential differential diagnosis EXCEPT

Cholecystitis

 

Diverticulitis

 

Correct!

Pancreatitis

 

Appendicitis

 

GET EXAM, QUIZ, OR ASSIGNMENT HELP HERE

Question 2

1 
/ 1
 pts

Sally is a 65-year-old patient who had a mammogram and biopsy positive for breast cancer. Her breast cancer is staged at T1N1M0. Sarah asks you what this means.

Correct!

T – tumor is 20 mm or smaller N – spread to 1 -3 axillary lymph nodes M – Not spread to distant body parts

 

T – tumor is 20 mm or bigger  N – spread to 5 or more  axillary lymph nodes M – Not spread to distant body parts

 

T – tumor is 40 mm or smaller N – spread to 1 -3 axillary lymph nodes M – Not spread to distant body parts

 

T – tumor is 40 mm or bigger  N – spread to 5 or more  axillary lymph nodes M – Not spread to distant body parts

 

Question 3

1 
/ 1
 pts

An ultrasound of the gallbladder confirms gall stones and  biliary stone obstruction in your 72-year-old patient complaining of right-sided abdominal pain, nausea, and vomiting that began after eating 3 days ago.  What non invasive procedure can be performed to treat this condition?

magnetic resonance cholangiopancreatography (MRCP)

 

Correct!

endoscopic retrograde cholangiopancreatography (ERCP)

 

hepatobiliary iminodiacetic acid scan (HIDA)

 

cholecystectomy

 

Question 4

1
/ 1
 pts

The NP is seeing an 80 year old male patient complaining of cramping abdominal pain, nausea, vomiting, and obstipation for the past 4 days.  PMH includes hernia repair, HTN, and atrial fibrillation.    Physical exam reveals a distended abdoment, hyperactive bowel sounds, and no rebound tenderness.   What is the initial diagnostic test you should order?

ultrasound

 

Correct!

Abdominal flat plate and upright

 

 

CT scan of the abdomen

 

MRI of the abdomen

 

Question 5

1 
/ 1
 pts

Salma is a 70-year-old female who has always had normal mammograms. She recently found a lump in her right breast upon self-examination in the shower. She is very concerned it could be breast cancer.  The NP explains to Salma that a breast lump is not always cancerous.  What are other potential causes of a breast lump?

Correct!

Mastitis

 

Correct!

Fibroadenoma

 

Embolism

 

Correct!

Fibrosis

 

NRNP-6540 week 7 KNOWLEDGE CHECK: ABDOMINAL, UROLOGICAL, AND GYNECOLOGICAL DISORDERS Question 6

1 
/ 1
 pts

Alex  is a 72-year-old patient who complains of worsening symptoms of BPH, his nocturia has increased significantly over the past year.    He has not tried any medication previsouly.     What first line medication would be appropriate to consider at this time?

 

oxybutynin

 

dutasteride

 

finasteride

 

Correct!

tamsulosin

 

Question 7

1
/ 1
 pts

The NP suspects cholecystitis and biliary tree obstruction in your 72-year-old patient complaining of right-sided abdominal pain, nausea, and vomiting that began after eating 3 days ago. Beside ultrasound, what other diagnostic tests could you order?

Correct!

 

magnetic resonance cholangiopancreatography (MRCP)

 

endoscopic retrograde cholangiopancreatography (ERCP)

 

hepatobiliary iminodiacetic acid scan (HIDA)

 

MRI of the abdomen

 

Question 8

1 
/ 1
 pts

 Armando
 is a 71-year-old patient the NP is seeing for his annual exam.    What ROS questions would you ask him about his genitourinary status?

Correct!

difficulty urinating

 

Correct!

urinary hesitancy

 

Correct!

decreased force of stream

 

Correct!

penile drainage

 

Question 9

1 
/ 1
 pts

The NP suspects cholecystitis and cystic duct obstruction  in your 72-year-old patient complaining of right-sided abdominal pain, nausea, and vomiting that began after eating 3 days ago. Beside ultrasound, what other diagnostic tests could you order?

magnetic resonance cholangiopancreatography (MRCP)

 

endoscopic retrograde cholangiopancreatography (ERCP)

 

Correct!

hepatobiliary iminodiacetic acid scan (HIDA)

 

MRI of the abdomen

 

Question 10

1 
/ 1
 pts

The NP is seeing an 80 year old male patient complaining of cramping abdominal pain, nausea, vomiting, and obstipation for the past 4 days.  PMH includes hernia repair, HTN, and atrial fibrillation.    Physical exam reveals a distended abdoment, hyperactive bowel sounds, and no rebound tenderness.   What is your working diagnosis?

appendicitis

 

gastroparesis

 

Correct!

bowel obstruction

 

irritable bowel syndrome

NRNP-
6540 week 7
KNOWLEDGE CHECK: ABDOMINAL, UROLOGICAL, AND GYNECOLOGICAL DISORDERS

DC is a 46-year-old female who presents with a 24-hour history of RUQ pain.  She states the pain started about 1 hour after a large dinner she had with her family.  She has had nausea and on instance of vomiting before presentation.

PMH: Vitals:
HTN Temp: 98.8oF
Type II DM Wt: 202 lbs
Gout Ht: 5’8”
DVT – Caused by oral BCPs BP: 136/82
HR: 82 bpm

Current Medications: Notable Labs:
Lisinopril 10 mg daily WBC: 13,000/mm3
HCTZ 25 mg daily Total bilirubin: 0.8 mg/dL
Allopurinol 100 mg daily Direct bilirubin: 0.6 mg/dL
Multivitamin daily Alk Phos: 100 U/L
AST: 45 U/L
ALT: 30 U/L
Allergies:

Latex

Codeine

Amoxicillin

PE:

Eyes: EOMI

HENT: Normal

GI:bNondistended, minimal tenderness

Skin:bWarm and dry

Neuro: Alert and Oriented

Psych:Appropriate mood

 

 
Pharmacotherapy for Gastrointestinal and Hepatobiliary Disorders

Accurate patient diagnosis is vital in ensuring that individuals receive the most appropriate and effective medical care tailored to their specific conditions. In the case of DC, a 46-year-old female presenting with right upper quadrant (RUQ) pain, a meticulous diagnostic approach is paramount. This paper delves into the comprehensive evaluation of DC’s medical history, physical examination findings, vital signs, current medications, and notable laboratory results to arrive at a precise diagnosis and initiate appropriate management.

BUY YOUR ESSAY HERE

Diagnosis and Rationale

The patient’s presentation suggests acute cholecystitis, an inflammatory condition of the gallbladder. The onset of pain after a large meal, particularly the RUQ pain, is consistent with gallbladder pathology, as gallbladder contraction triggered by dietary fat can exacerbate symptoms in patients with cholecystitis (Tanaja & Meer, 2019). Nausea and vomiting are also frequently associated with gallbladder inflammation due to the release of inflammatory mediators. These symptoms, along with a history of hypertension (HTN), type II diabetes mellitus (DM), and gout, indicate potential risk factors for gallstone formation (Zhang et al., 2022). The presence of minimal tenderness on abdominal examination supports this diagnosis. Additionally, a history of deep vein thrombosis (DVT) related to oral contraceptive pills (BCPs) might indicate hormonal influences on gallstone development.

Drug Therapy Plan

In light of the acute cholecystitis diagnosis, the recommended drug therapy plan consists of pain management, antiemetics, antibiotics, and cholecystectomy consultation. Analgesics, specifically nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, should be prescribed to alleviate pain and reduce inflammation. However, caution is necessary due to the patient’s history of HTN. Thus, short-term NSAID use and vigilant blood pressure monitoring are essential (Ghlichloo & Gerriets, 2023). To manage nausea and vomiting, antiemetic medications such as ondansetron can be administered. This will enhance the patient’s overall comfort and well-being. Broad-spectrum antibiotics like ciprofloxacin and metronidazole should be initiated promptly to address potential bacterial infection within the gallbladder. The patient should be referred for a surgical consultation for cholecystectomy, which serves as the definitive treatment for acute cholecystitis. According to Hassler and Jones (2019), laparoscopic cholecystectomy is the preferred surgical approach in most cases.

Conclusion

The comprehensive assessment of DC’s case underscores the importance of precise diagnosis and tailored drug therapy plans in the realm of healthcare. With a strong indication of acute cholecystitis based on her clinical presentation and medical history, our recommended drug therapy plan, encompassing pain management, antiemetics, antibiotics, and a cholecystectomy consultation, aligns with established guidelines for this condition. This case exemplifies the critical role that accurate diagnosis plays in guiding patient care, ensuring timely interventions, and ultimately improving the overall quality of life for individuals like DC. In the pursuit of effective healthcare delivery, a patient-centred approach that integrates diagnosis, treatment, and ongoing monitoring remains essential to achieving the best possible outcomes.

References

Ghlichloo, I., & Gerriets, V. (2023, May 1).
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK547742/

Hassler, K. R., & Jones, M. W. (2019, March 22).
Laparoscopic cholecystectomy
. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448145/

Tanaja, J., & Meer, J. M. (2019, January 27).
Cholelithiasis
. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470440/

Zhang, Y., Sun, L., Wang, X., & Chen, Z. (2022). The association between hypertension and the risk of gallstone disease: a cross-sectional study.
BMC Gastroenterology
,
22
(1). https://doi.org/10.1186/s12876-022-02149-5

DC is a 46-year-old female who presents with a 24-hour history of RUQ pain.  She states the pain started about 1 hour after a large dinner she had with her family.  She has had nausea and on instance of vomiting before presentation.

PRAC-6540 Week 7: Quiz DIAGNOSTIC IMAGING AND LABS

Question 1

1 
/ 1
 pts

The EKG or ECG is looking at the electrical activity of the heart. True or false?

True

 

False

 

Incorrect
Question 2

0 
/ 1
 pts

Your 70-year-old male patient has finished a surgical resection and radiation for prostate cancer. What do you expect his PSA to be in 6 months?

<5 mg/ml <4 mg/ml <0.5 mg/ml <0.1 mg/ml Incorrect Question 3 0  / 1  pts The beating of the heart is controlled by: Nerve cells   Myocardiocytes   Muscle fibers   All of the above   ORDER EXAM, QUIZ, OR ASSIGNMENT HELP NOW Question 4 1  / 1  pts Your 70-year-old married male patient comes to the clinic stating he has had “trouble in the sex department.” You check his testosterone level, and it comes back as <275 pmol/L. You determine this result is: Normal for his age   Low   High   High normal   PRAC-6540 Week 7: Quiz DIAGNOSTIC IMAGING AND LABS Question 5 1  / 1  pts Key things about X-rays are that: X-rays are less likely to penetrate dense materials (like bone)   X-rays are like a negative   Black areas on an X-ray indicate an air-filled space   All of the above are correct   Question 6 1  / 1  pts The electrical conduction of the heart follows which pathway? Atrioventricular (AV) node – sinoatrial (SA) node – His bundle – Purkinje fibers   Sinoatrial (SA) node – atrioventricular (AV) node – His bundle – Purkinje fibers   Sinoatrial (SA) node – His bundle – Purkinje fibers – atrioventricular (AV) node   Purkinje fibers – sinoatrial (SA) node – His bundle – atrioventricular (AV) node   Question 7 1  / 1  pts Your 73-year-old diabetic patient has a urinary albumin excretion of >30 mg/dl. You order a 24-hour urine test to determine chronic kidney disease (CKD). The results are GFR 60–89 mL/min/1.73m2 and persistent albuminuria. What stage of CKD is this?

Stage G1

 

Stage G2

 

Stage G4

 

Stage G5

 

Question 8

1 
/ 1
 pts

When performing a CBC on your older adult, all of the following values are within normal levels EXCEPT:

WBC 15,000

 

Lymphocytes 29

 

Hemoglobin 15

 

Platelets 227,000

 

Question 9 PRAC-6540 Week 7: Quiz DIAGNOSTIC IMAGING AND LABS

1 
/ 1
 pts

Reading a chest X-ray can be done using the letters A B C D E F G. These stand for:

A: Assessment—image quality; B: Bones; C: Cardiac silhouette

 

D: Diaphragm; E: Equipment—look for images of lines, pacemakers, etc.; E: Effusions

 

F: Lung fields; G: Great vessels—look for the great vessels and their positions, and symmetry

 

All of the above are correct

 

Question 10

1 
/ 1
 pts

When reviewing an X-ray, all of the following are correct EXCEPT:

Black areas = air

 

Dark grey = fat

 

Bright white = metal

 

Light grey = bone (correct answer is soft tissue)

PRAC-6540 Week 7: Quiz DIAGNOSTIC IMAGING AND LABS

The Affordable Care Act case study essay

The Affordable Care Act provides a wide spectrum of quality improvement activities that are divided into three main categories which includes evaluating new models of healthcare, focusing reimbursement from volume to quality, and overall system improvement. As nurse practitioners, we are responsible for fostering these changes in our clinical practice. Chapter seven looks at various key aspects of the ACA and the health reforms it focuses on.

Read chapter 7 of the textbook and complete the case study questions for chapter

Guidelines

Your assignment submission should be 200-250 words in length. It should contain proper grammar, be free of spelling errors, and reflect critical thinking.  Submit your assignment utilizing the APA 7th Edition format. Ensure all references are properly cited. Remember if it is not your original thought process, you need to provide a reference.

 

BUY YOUR ESSAY HERE

Case Study, Chapter 7 

Question 1

The American Health Care Act (AHCA) and the Better Care Reconciliation Act (BRCA) which were the bills aimed at repealing and replacing the Affordable Care Act (ACA) did not gather enough support in Congress to become law. These bills aligned with the healthcare reform priorities of the party and had some elements. They intended to lower taxes as Republicans generally prefer government involvement in healthcare (Chapter 7). Additionally, they aimed to eliminate government mandates, the mandate and decrease federal spending on healthcare aligning with fiscal conservatism. Their goal was to make health insurance more affordable for sicker individuals. This was planned by allowing insurers to charge premiums for individuals and reducing requirements for essential health benefits. However, these bills faced criticism due to consequences such as reduced coverage for populations and uncertainty in the market. Understanding these characteristics provides insights into how Republicans approach healthcare reform.

Question 2

There are ways to address the mandate, in the Affordable Care Act (ACA) that could help minimize political unrest. One option is for policymakers to introduce rewards or tax credits as a means of encouraging people those with lower incomes to voluntarily enroll in health insurance. This approach has its advantages such as reducing government interference and respecting choices (Williams & Dhillon, 2019). However, it may not be as effective in achieving coverage. In the healthcare sector we have seen examples of incentives like employer sponsored wellness programs and Medicaid expansion incentives, for states, which highlight their potential in promoting enrollment and encouraging health behaviors. However, it is important to acknowledge that there are tradeoffs and complexities associated with these approaches.

Question 3

The pros of having a public option include increased competition, potentially lower costs, and broader access to healthcare. It could provide a safety cushion for individuals who cannot afford insurance. However, there are concerns regarding government control the possibility of costs if not properly managed and opposition from insurers (Chapter 7). The Office of Personnel Managements compromise was designed to increase competition by partnering with multistate plans accomplishing some of the objectives of an option without relying on government run healthcare. This compromise may have been acceptable to lawmakers because it strikes a balance between private interests addressing worries, about government involvement while fostering competition and affordability.

Question 4

Compromising on the state role in the ACA has both advantages and disadvantages. On the positive side, allowing states greater flexibility can lead to more rapid innovation in healthcare policy tailored to local needs. State legislatures might find it more convenient to cater to a group of constituents which could potentially promote stability (Mackintosh & Armstrong, 2020). Nevertheless, this approach carries the risk of creating a fragmented landscape of healthcare programs and policies across states. This fragmentation could undermine the consistency and consumer protections at the level. The publics ability to access health insurance and healthcare services may greatly vary depending on each states approach. For instance, in states like California or New York where healthcare policy has historically been more advanced granting control to the state may improve access to care. On the other hand, in states like Texas or Florida that have demonstrated resistance towards expanding healthcare access it could lead to disparities in terms of both accessibility and affordability (Chapter 7). Therefore, while allowing flexibility at the state level presents opportunities for innovation, it is crucial to consider striking a balance between state autonomy and national coherence in order to ensure equal access to healthcare throughout the entire country.

 

 

References

Chapter 7. Affordable Care Act Reframed and uncertain.

Mackintosh, N., & Armstrong, N. (2020). Understanding and managing uncertainty in health care: revisiting and advancing sociological contributions. 
Sociology of Health & Illness
, 
42
, 1-20.

Williams, S. A., & Dhillon, S. (2019). Women’s obstetric and reproductive health care discourse in online forums: perceived access and quality pre-and post-Affordable Care Act. 
Preventive Medicine
, 
124
, 50-54.

Chapter 7 Case Study Questions

Discussion Question 1

Even though the primary legislative bills to repeal and replace the Affordable Care Act (ACA)—the AHCA and BRCA—did not have sufficient support across U.S. Congress to become law, and some of their provisions may not have been allowed under reconciliation rules, it is worth considering the main features of the bills to understand the type of health reform changes many Republicans support (see TABLE 7-1). Overall, these bills reduced taxes, eliminated government mandates, lowered federal government spending, lowered premiums health insurance more affordable for elderly and sicker individuals?

Discussion Question 2

Are there alternatives to the individual mandate that accomplish the same goals without engendering so much political turmoil? Could policymakers have designed an incentive system that would be as effective as a mandate? What are the pros and cons of using a mandate versus an incentive? Can you think of incentives to encourage enrollment that have occurred in other parts of the healthcare system? The Affordable Care Act case study essay

Discussion Question 3

There was a lengthy debate about whether to include a public option in health reform. A public option is some type of government-run health plan that would be available to compete with private plans. A public option could exist within the health exchange model or outside of it. Instead of a public option, Congress voted to require the Office of Personnel Management, which runs the Federal Employees Health Benefit Program, to contract with at least two multistate plans in every state health insurance exchange. What are the pros and cons of having a public option? Does the Office of Personnel Management compromise achieve all or some of the goals of having a public option? Why do you believe the Office of Personnel Management compromise was acceptable to legislators but the public option was not?

Discussion Question 4

Republican policymakers that are involved in bipartisan discussions to revise the ACA are focused on providing states with increased flexibility regarding benefit design, premium pricing, and other features. Although states are generally home to social welfare changes, it is difficult to provide universal health care on a state-by-state basis. If state health reform efforts lead the way, the country could have a patchwork of programs and policies that vary from state to state, with the potential to make health coverage even more complex and inefficient than it is currently. On the other hand, it is also important to recognize that a health reform strategy focusing on states has benefits as well. At its best, state-level reform can be accomplished more rapidly and with more innovation than at the federal level. State legislatures may have an easier time convincing a narrower band of constituents important to the state than Congress has in accommodating the varied needs of stakeholders nationwide. What are the advantages and disadvantages of compromising regarding the state role in the ACA? Is it worth giving up some degree national uniformity and stronger consumer protections in exchange for political stability and allowing state to experiment with health reform design? How well do you think the public will be served in their access to affordable health insurance and access to health care if states have more control? How does your response differ if you are living in California or New York versus Texas or Florida?

The Affordable Care Act case study essay Discussion Question 5

A group of friends were talking about the Affordable Care Act (ACA), illustrating the wide-ranging viewpoints about the law. Calvin, whose daughter Mia is struggling to make a living as an artist, is pleased that Mia has health insurance for the first time since graduating from college. Although Mia cannot stay on her parents’ insurance because she just turned 27, she can now afford a good health insurance plan that she found on her state’s health exchange. While Calvin has not noticed much of a change in his own health insurance coverage, which he obtains through his government employer, his friend Katherine is upset about health reform. She does not want the government forcing her to purchase health insurance (although she always chose to be insured in the past), and she recently found out that her old plan was cancelled because it did not meet the law’s requirements. Katherine found several new plan options to choose from, but none had her exact combination of benefits, providers, and price. In addition, Katherine’s uncle, Ethan, is 55 years old and self-employed. He purchases his health insurance on his state’s exchange and because he has preexisting conditions, he is grateful to be able to find a plan. Even so, Ethan’s premiums will increase by 15% this year and his deductible is $5,000, making health care difficult to afford even with insurance. Another friend, Jara, told Katherine she should be willing to pay a little more or change some aspects of her plan to help the millions of people who can now afford insurance for the first time as a result of the ACA. After witnessing her uncle’s experience, however, Katherine is skeptical that the government is going to be able to keep its promises.

What are the competing viewpoints about the ACA exemplified by these friends? Which of these friends’ views will be the most pressing concern going forward in the discussions about the ACA? The Affordable Care Act case study essay

Importance of cultural competence in nursing practice

The nursing profession is a crucial field in the healthcare sector. Nurses play important roles in providing high-quality care to patients who belong to different cultural environments. For that reason, cultural competence nursing practice is necessary to improve patient outcomes and enhance the quality of patient care.

Through cultural competence, nurses can provide better care and contribute to more inclusive and impartial healthcare programs. In this blog post, we will explore why cultural competence is important in nursing practice and its impact on patient outcomes.

What is cultural competence?

Cultural competence refers to the ability of healthcare professionals such as nurses to respect, understand, and be able to honor and attend to the needs of the patients. It helps nurses to be sensitive and respectful to the beliefs of the patients about the choice or decisions of healthcare. Cultural competence is responsible for improving the quality of care that nurses give, patient outcomes, and fostering trust. Here are some key aspects of cultural competence in nursing:

Cultural awareness

Understanding one’s own beliefs, culturally shaped values, perceptions, and biases is very important in patient care. As a nurse, being aware of the cultural background of the patient and being conscious of how it impacts their perceptions and relations is significant.

BUY A CUSTOM-WRITTEN ESSAY HERE

Cultural intelligence

Engaging in continuous education on cultures and cultural practices of the patient’s background is a number one role as a nurse. Through this practice will be able to acquire the necessary knowledge to understand cultural beliefs about illness healing and health.

Cultural sensitivity

This is the state of being compassionate and empathetic towards patients from different backgrounds. As a nurse, you must be aware and ready to accept the cultural differences of your patients without making judgments, stereotypes, or assumptions based on them.

Effective interaction

Effective communication skills are necessary in the nursing profession. These will help the nurses interact with patients with different languages. Nurses should have knowledge and skills in non-verbal communication, body language, and cultural cues.

Flexibility

Nurses should be able to adapt to their work environment and understand what works for different patients based on their cultural differences. It is important to recognize that what works for one patient may not work for another, and the nurses should be prepared to make care plans that will meet the different needs and preferences of every patient.

Respect

Nurses need to treat each patient with respect and honor despite their cultural environment. They should understand and accept the values, practices, and cultural beliefs of the patients, even if they are different from theirs.

Cooperation

Nurses should be willing to collaborate with interpreters of cultural liaisons when needed to enable understanding and effective interactions between them and patients who might have different languages and unique cultural needs.

Assessment

A cultural assessment is crucial in gathering data or information on a patient’s background. This assessment helps nurses understand how the cultural background of a patient might impact their well-being and healthcare decisions.

Training

Ongoing learning and training on cultural competence are important in helping nurses, and other healthcare providers acquire the necessary skills for dealing with the needs of patients with unique needs and from different cultural backgrounds.

Self-improvement

Cultural competence is an ongoing program nurses should participate in, seeking feedback from patients, self-reflection, and constantly working to improve it throughout their profession.

Impact of cultural competence on patient outcomes

Cultural competence plays a pivotal role in improving patient outcomes. Due to the practice of cultural competence in the healthcare landscape, there is a positive influence of different features of patient care, which leads to an improvement in patient outcomes.

The following are ways in which cultural competence impacts patient outcomes:

Improved communication

Effective communication leads to accurate diagnosis and treatment procedures and also helps in overcoming language barriers. This will enable the patients to communicate their concerns, symptoms, and preferences effectively.

Enhance trust and empathy.

Cultural competence practised by healthcare providers will enhance trust and empathy in patients. This will make the patients have open and honest communication with the nurses, which is important for effective care.

Precise diagnosis and treatment

Being aware of the cultural information of the patient will help in conducting an accurate assessment and diagnosis. This will help in providing the necessary and suitable treatment, preventing misdiagnosis.

Considerate treatment strategies

Through practicing cultural competence, healthcare providers can come up with treatment strategies that consider patients’ values, preferences, and cultural beliefs. The patients are going to follow the treatment strategies as they are considerate of your culture, resulting in better outcomes.

Improved treatment constancy

Cultural competence practices will enable healthcare providers to prescribe medications and use treatment procedures that align with the patient’s cultural beliefs. Due to this, patients are going to adhere to the treatment procedures and medications recommended to them, leading to better outcomes.

Decreased health discrepancies

It helps the healthcare providers to give equal care to all the patients regardless of their cultural backgrounds. This will decrease health discrepancies that unequally affect the minority community.

Mental well-being

Respect and understanding of patients’ unique needs reduce stress and anxiety among them. This promotes mental well-being, which greatly leads to recovery and healing.

Patient contentment

Cultural competence increases the level of patient satisfaction, which makes them participate in their health care and become active in managing their health.

Prevention and health promotion

Cultural competence in healthcare helps in providing preventive procedures and health education that are acceptable to patients, resulting in better health and decreased risk of long-term conditions.

Prevent hospital readmission

Including cultural competence practices in the discharge plans and follow-up care will help the patients to understand follow-up hospitalization regulations, which will reduce readmissions, hence leading to cost savings for healthcare systems.

Role of cultural competence in overcoming language barriers in healthcare

Language barrier is one of the problems faced in the healthcare sector. Cultural competence plays a pivotal role in overcoming language barriers in healthcare. Here are some ways in which cultural competence helps in overcoming language barriers in healthcare:

Enabling effective communication

Cultural competence facilitates healthcare providers with a better understanding of the cultural information of the patients and language preferences. Culturally competent nurses use interpreters to bridge the language gap.

Respecting language choices

Cultural competence encourages the act of respecting the language preference of the patient. A culturally competent healthcare provider should be willing to accept the language choices of the patient.

Trained language interpreters

Cultural competence from what’s the value of trained interpreters in the healthcare sectors instead of depending on untrained individuals. Culturally competent care providers are aware that trained interpreters adhere to accuracy, confidentiality, and cultural sensitivity in communication.

Providing care and training

Healthcare providers convert their training materials and care plans to be culturally suitable. This helps make sure that patients can understand follow-up regulations, diagnosis, and treatment strategies.

Creating trust

Cultural competence helps in overcoming language barriers, which builds trust between patients and healthcare providers. This trust will make the patients follow the advice of the healthcare providers who express respect towards their language and culture.

Decreasing health disparities

The language barrier is a main cause of health care disparities among minority populations full stop through cultural competence, or patients can get equicare despite their language competence, which reduces health disparities.

Improving patient-centred care

Healthcare providers who are culturally competent understand and attend to patient’s cultural needs. This is a clear reveal of how they prioritize patient-centered care by considering patient’s values and preferences.

Improving patient contentment

Giving care that is culturally competent to patients will increase their level of satisfaction, which makes them adhere to treatment plans and improve healthcare outcomes.

Ethical considerations in culturally competent care

Here are some ethical considerations in culturally competent care:

Autonomy

Ethical healthcare practice acknowledges and honors the autonomy of patients. Healthcare providers should include patients in decision-making procedures that involve cultural perspectives when it comes to treatment processes.

Impartial treatment

This is one of the major principles of medical ethics. Ethical healthcare practice supports equal treatment of all patients despite their cultural backgrounds. Discrimination is one of the causes of disparities and is unacceptable in healthcare.

Privacy

Healthcare providers have an ethical duty to conserve the confidentiality and privacy of their patients by respecting cultural standards concerning fairness and privacy.

Informed consent

Healthcare providers should make sure that informed consent procedures are culturally suitable to enable an understanding of the benefits, risks, and alternatives of a certain treatment method to patients.

Religious and cultural sensitivity

Healthcare providers should be sensitive and respectful of the religious and cultural beliefs of their patients. Ethical and cultural competence care involves considering these beliefs when analyzing treatment options, ethical dilemmas, and end-of-life decisions.

Continuing education and training

Ethical healthcare providers should maintain cultural competence by engaging in ongoing education. These will keep them updated with the latest practices that will enable them to provide the best care to all patients regardless of their cultural background.

End-of-life care

When it comes to end-of-life care, cultural competence is very crucial. Healthcare providers must have an understanding of the cultural differences in perspectives concerning death decision-making and procedures related to death and mourning.

Access to language and interpreters

Ethical competence care needs the use of trained interpreters in case of language barriers. Professional interpreters are better than depending on untrained individuals who might compromise patient confidentiality and quality care.

To wind up

Cultural competence is a very crucial skill in the diverse healthcare field. It helps in enhancing the quality of care, fostering trust and patient outcomes. Cultural competence goes past service-level awareness of cultural diversity and contains knowledge of the values, traditions, and beliefs that impact patients’ healthcare outcomes and decisions.

If you need more information on the importance of cultural competence in nursing, our medical assignment help is here for you. Visit our platform at;
onlinenursingpapers.com
for quality nursing assistance.

Scott Becker gastrointestinal system hourly rounds shadow health Blood Transfusion

Blood Transfusion: 13.5 of 15 (90.00%)

 

Prompt

Learner Response

Model Response

Preceptor Diana: Based on these updated lab values, what factors indicate the need for intervention for this patient?

Attempt 1:

 Hemoglobin of 7.8 and hematocrit of 23.4%

Score: 
1 
out of
 1

Attempt 1:

Correct! While all of these answers include this patient’s abnormal values, the hemoglobin and hematocrit indicate a need for intervention Scott Becker gastrointestinal system hourly rounds shadow health Blood Transfusion

Preceptor Diana: Review the information in the EHR and the labs that were ordered in the emergency department and then choose the best course of action.

Attempt 1:

 Recheck vital signs and compare to previous values

Attempt 2:

 Transfuse 1 unit of PRBCs

Score: 
0.5 
out of
1
Scott Becker gastrointestinal system hourly rounds shadow health Blood Transfusion

Attempt 1:

This is not the most appropriate answer. The incorrect answer you selected has been removed. Try again with the remaining selections.

Attempt 2:

Correct! Because of the low hemoglobin and hematocrit of the patient, and because the type and cross has already been completed, the best course of action is to transfuse blood into the patient.

How do you know the transfusion works (cite evidence from labs/tests and from patient interaction)?

 The transfussion worked because the patient reported to feeling better than before afteer the procedure

The patient’s vitals will improve. After ordering a follow-up CBC, the patient’s hemoglobin and hematocrit levels will improve as well.

What do you do if there is no transfusion reaction but there is also no improvement in the patient’s condition?

 Patient should be monitored closely and an anti-body screening test should be conducted

If there is no improvement in a patient’s condition after the transfusion is complete, the next step is to call the provider and implement an updated care plan.

Under what conditions would you call for more blood?

 When a patient has severe anemia or injury that has made them loose alot of blood

It would be appropriate to call the blood bank for more blood if the patient’s condition does not improve after the first transfusion, or if they have active bleeding and their hemoglobin continues to drop
Scott Becker
gastrointestinal system hourly rounds shadow health Blood Transfusion.

Scott Becker shadow health Subjective Data Collection

Subjective Data Collection: 26 of 26 (100.0%)

Hover To Reveal…

Hover over the 
Patient Data 
items below to reveal important information, including 
Pro Tips
 and 
Example Questions
.

Found:

 Indicates an item that you found.

Available:

 Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Patient Check In

Finding:

Asked about chief complaint

GET SHADOW HEALTH OR EXAM HELP HERE

Finding:

Reports fatigue

(Found)

Pro Tip: By asking a patient an open question about their reason for coming into the hospital, you can establish their current medical and comfort needs and assist in coordinating their care.

Example Question:

What brings you to the hospital?

Finding:

Reports small amount of blood in vomit

(Found)

Pro Tip: By asking a patient an open question about their reason for coming into the hospital, you can establish their current medical and comfort needs and assist in coordinating their care.

Example Question:

What brings you to the hospital?

Finding:

Reports stomach pain

(Found)

Pro Tip: By asking a patient an open question about their reason for coming into the hospital, you can establish their current medical and comfort needs and assist in coordinating their care.

Example Question:

What brings you to the hospital? Scott Becker shadow health Subjective Data Collection

History of Present Illness

Finding:

Followed up on fatigue

Finding:

Reports worsening fatigue over several weeks

(Found)

Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How long have you felt fatigued?

Finding:

Followed up on vomit

Finding:

Reports vomiting only once

(Found)

Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How often have you been vomiting?

Finding:

Reports vomiting this morning

(Found)

Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

When did you vomit?

Finding:

Reports noticing dark flecks in vomit

(Available)

Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

What was your vomit like?

Finding:

Followed up on stomach pain

Finding:

Reports pain in upper-left abdomen Scott Becker shadow health Subjective Data Collection

(Found)

Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Where is your stomach pain?

Finding:

Reports stomach pain is gnawing or burning

(Found)

Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How would you describe the stomach pain?

Finding:

Reports experiencing stomach pain for past 3 to 4 months

(Found)

Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How long have you had stomach pain?

Finding:

Reports stomach pain worsens after eating

(Found)

Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Does the pain get better or worse after eating?

Finding:

Reports stomach pain increasing over the past week

(Found)

Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Has your stomach pain gotten worse over time?

Finding:

Reports taking antacids daily Scott Becker shadow health Subjective Data Collection

(Found)

Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you take anything for your stomach pain?

Finding:

Reports antacids are moderately effective

(Found)

Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Does anything relieve your stomach pain?

Past Medical History

Finding:

Asked about allergies

Finding:

Denies food allergies

(Available)

Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

Example Question:

Do you have any food allergies?

Finding:

Denies environmental allergies

(Found)

Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

Example Question:

Do you have any environmental allergies?

Finding:

Denies latex allergy

(Available)

Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

Example Question:

Are you allergic to latex?

Finding:

Denies medication allergies

(Found)

Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

Example Question:

Do you have any medication allergies?

Finding:

Asked about existing health conditions

Finding:

Reports hypertension

(Found)

Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

Example Question:

Do you have any existing health conditions?

Finding:

Reports high cholesterol

(Found)

Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

Example Question:

Do you have any existing health conditions?

Finding:

Reports coronary artery disease

(Found)

Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

Example Question:

Do you have any existing health conditions?

Finding:

Reports osteoarthritis

(Found)

Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

Example Question:

Do you have any existing health conditions?

Social History

Finding:

Asked about living situation

Finding:

Reports living with family

(Found)

Pro Tip: A patient’s social history encompasses a patient’s social, cultural, economic, and lifestyle factors that together influence the patient’s health. Asking a patient about subjects such as common lifestyle activities and substance use can help you gain understanding about a patient’s social history.

Example Question:

What is your living situation?

GET SHADOW HEALTH HELP HERE

Finding:

Asked about tobacco use

Finding:

Denies tobacco use

(Found)

Pro Tip: A patient’s social history encompasses a patient’s social, cultural, economic, and lifestyle factors that together influence the patient’s health. Asking a patient about subjects such as common lifestyle activities and substance use can help you gain understanding about a patient’s social history.

Example Question:

Do you use any tobacco products?

Finding:

Asked about caffeine use

Finding:

Reports drinking coffee

(Found)

Pro Tip: A patient’s social history encompasses a patient’s social, cultural, economic, and lifestyle factors that together influence the patient’s health. Asking a patient about subjects such as common lifestyle activities and substance use can help you gain understanding about a patient’s social history.

Example Question:

Do you consume caffeine?

Finding:

Reports drinking coffee every morning

(Found)

Pro Tip: A patient’s social history encompasses a patient’s social, cultural, economic, and lifestyle factors that together influence the patient’s health. Asking a patient about subjects such as common lifestyle activities and substance use can help you gain understanding about a patient’s social history.

Example Question:

How often do you drink coffee?

Finding:

Reports drinking 2 to 3 cups

(Found)

Pro Tip: A patient’s social history encompasses a patient’s social, cultural, economic, and lifestyle factors that together influence the patient’s health. Asking a patient about subjects such as common lifestyle activities and substance use can help you gain understanding about a patient’s social history.

Example Question:

How many cups of coffee do you have in a day?

Finding:

Asked about alcohol use

Finding:

Reports alcohol use

(Found)

Pro Tip: A patient’s social history encompasses a patient’s social, cultural, economic, and lifestyle factors that together influence the patient’s health. Asking a patient about subjects such as common lifestyle activities and substance use can help you gain understanding about a patient’s social history.

Example Question:

Do you drink alcohol?

Finding:

Reports drinking 1 to 2 nights a week

(Found)

Pro Tip: A patient’s social history encompasses a patient’s social, cultural, economic, and lifestyle factors that together influence the patient’s health. Asking a patient about subjects such as common lifestyle activities and substance use can help you gain understanding about a patient’s social history.

Example Question:

How often do you drink alcohol?

Finding:

Reports having 1 to 2 glasses per sitting