After reviewing the case study below, what are your top priorities in assessment for this patient? Be sure to consider all parts of the individual’s situation, including cultural, psychosocial and physical. Scholarly article only to be used as reference, within last 5 years.
Musculoskeletal Clinical Case
A 40-year-old Asian American male, who works as a roofer, complains that three days ago he was lifting a heavy object at work, following which he got low back pain. The pain is in the middle of the back near his waist. The pain increases when he bends forward and he is experiencing numbness and tingling in the toes of his right foot. He has had similar symptoms before, but it has not been so bad in the past. This is the worst he has had because in the earlier instances, he has never had the tingling sensation in his right foot before.
In the past, he got better with rest and some Ibuprofen. He is worried that he will not be able to continue his work and make money. He is out of work as a result of the pain. He has a lot of difficulty getting sleep at night. He has started taking some of his friend’s medication and it seems to help.
He has pain in the mid lumbar area, which radiates to the right buttock. He also has numbness and tingling down the back of his right thigh to his toes. The pain and numbness has been increasing since the problem started three days ago. He has tried over-the-counter Ibuprofen and some stretching exercises, but it does not seem to help. He has not sought any medical care yet. In the past, the pain had just gone away, but this time the pain is persistent. There is a gradual worsening of his symptoms and he is concerned about the pain that has been increasing steadily over the past three days. He is wondering whether he has a herniated disc. His major concern is that he has no health insurance and will be missing work.
He has had similar pain in the past, but it was not so severe. He saw a chiropractor around two or three years ago and that gave him some relief. Otherwise, the patient has no chronic medical problems. He does not seek medical care on a routine basis.
Page 1 of 5
He has had no diagnostic measures in the past. He has never had any blood work reports, CT scan reports, X-ray reports and so forth done in the past. He has been gaining weight over the past few years and does not do any stretching exercises before work. Patient does not have any other risk factors. There are no records of any past surgeries. He has neither had any significant illnesses in the past nor any hospitalizations.
Pain in the mid lumbar area radiating to the right buttock. There is a tingling sensation that goes down the back of his right thigh to the toes. He does not have urinary or bowel incontinence. No nausea, vomiting, or fever. He denies abdominal pain and pain with urination. There is no gross hematuria.
Patient does not take any prescription medications, only over-the-counter Ibuprofen. He is using 800mg of Ibuprofen every four hours. Patient is compliant with the prescribed regimen; in fact, he could be using too much. Patient is seeking care because of the increasing pain. He has tried chiropractic manipulations in the past for low back pain.
He is allergic to Penicillin. It has caused a rash in the past.
This patient works for a local roofing company and makes $30,000.00 per year, which is just a little over the minimum wage. He has a high school education certificate and makes just enough money to get by. He has no health insurance. The patient feels that the last thing that he wants to do is spend money on healthcare. He feels his body will get better on its own, and so he can just keep working. He made the appointment at this outpatient clinic because his friends told him about it. He was not sure where to go for help. He has decreased access to healthcare because he is not aware of the services available. The patient has had essentially no healthcare to date. The patient states that he is starting to realize that his body will not last forever at his current position as a laborer.
The patient is divorced and thinks he was a failure as a husband. He is behind in alimony payments. His wife is alive and well without any medical problems. They do not communicate anymore. They have no children. He would like to try and get back together with her, but she refuses to speak to him. He has been holding himself back from expressing the amount of stress he has in life for many years. He thinks he is becoming depressed as a result of this. His parents still live in the area and he sees them every weekend. He has friends from work and they do social things together. The patient has not sought any emotional support from anybody. There is no element of family dysfunction. He becomes easily stressed out. He lives in social isolation from his community. The patient has always taken his health for granted and not thought much about it in the past.
Smoking: Non smoker
Alcohol: Drinks at bars on weekends to excess with his friends
Substance abuse: He smokes marijuana.
He skips breakfast and eats at fast food restaurants twice every day. He sips coffee and caffeinated beverages throughout the day. The patient feels that his job gives him enough exercise and so he need not do anything else. He plans to go on a “diet” soon to lose the weight he has gained over the past few years, but is not sure about the diet he is going to follow.
The patient works as a roofer. He has had other labor-intensive jobs in the past that do not require an educational background. He does not enjoy his job. He knows it is a dead end job and wants to go to school. He is originally from United States and lives in a suburban community where resources are easily accessible, but he is not aware of them.
Both parents have hypercholesterolemia. His 65-year-old father has prostate cancer. Both parents are being treated with medications for their high cholesterol levels. He has no siblings. There is a remote history of heart disease in his relatives.
Vital Signs: Ht: 6′; Wt: 220; WC: 40; BP: 120/78; T: 97 po; P: 92 and regular; R: 18 non-labored
Lymph Nodes: None
Heart: RRR without murmur
Carotids: Not examined
Abdomen: Android obesity, otherwise benign
Rectum: Not examined
Extremities, Including Pulses: 2+ pulses in the lower extremities
Mental Status: Alert and oriented
Cranial Nerves: II – XII intact
Motor Strength: Upper extremities equal strength 5/5.
Lower extremities: decreased strength of right leg with resisted extension; patient complains of pain in posterior thigh.
Sensation (light touch, pin prick, vibration, and position): Decreased sensation of right leg along L5 : S 1 dermatome to pin prick stimulation compared with the left.
Reflexes: DTRs 2+ in upper and lower extremities
Cerebellar function intact—Romberg test is negative; heel-to-toe walking is steady.
Postive straight leg raise on the right at 20 degrees.
LAB RESULTS/RADIOLOGICAL STUDIES/EKG INTERPRETATION
UA dip stick: WNL
Plain film of lumbar spine: loss of disc height at L5 to S1. Mild degenerative changes of lumbar vertebrae.
MRI: moderate disc bulge at L5: S1.
EKG: Not performed
application for MPH
1-first part has to include your relevant experience and why is it you want to achieve by the end of MPH (master in public health) why its important for you
a medical doctor so you have the knowledge and a small experience in your practice and interested in public awareness …and see your degree and the master degree go hand in hand to achieve it could do it in more professional way.
studying and retaining back to practice will enhance your ability, your self joining the UN after finishing your master in international public health in 2 years hopefully you could practice and apply what you took from this master in your professional day to day
2nd question should be answered in the essay :
what have you learned from the work experience that you will bring in to classroom in terms of insight about health , illness and public health…..as a doctor although you have a short work experience
3rd part of the essay should be on how did you identified a new approach to a complex problem?!!
4th part describe a situation where you got people working to gather how you did it and what’s the impact was ?
the 4 questions or points should be answered in the essay
the complex problem actually its not a problem in precise its was a difficult case that you had in your internship
a patients who’s immune compromised and almost had an allergy against any thing you could imagine cloth material , serums , certain antibiotics so me and the team decided when ever we approach her we should take a full measures a crash cart, and senior in charge should be close even the consultant when ever we needed to do any thing to the patient ,,, after you finished the rotation and endorse her to the new intern, the new intern flowed your way with this patient
Based on previous PIcot question
Presenting a Poster
You will submit a poster depicting your work. Download View in a new window
Creativity is encouraged for this part of the project, but do not forget to address the elements required from the rubric.
Poster Grading Rubric
Clinical Question PICOT:
Display PICOT question in correct format.
Define the process steps for the search (define the MeSH headings, search terms, databases used and choosing the appropriate database, inclusion and exclusion criteria for the search)
Rate and Critical Appraisal of Evidence
Identification of 3 articles relevant to assigned priority area
Level of evidence and provision of summation
Appraisal to include strengths and limitations, risk level for intervention, and feasibility of use in practice
Integration and Translation
Evaluate anticipated outcomes of integration and translation
Poster completion (publishing, podium presentation, poster)
Organization, creativity, completeness
3-5 bullet points summarizing results of EBP, translation, and outcomes on defined priority area
Implications for nursing
Cardiac issues /care plan/diagnoses
Analyze the case study assigned to you at the outpatient clinic. Create a holistic care plan for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-9 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
•Search term page to identify the codes applicable to the care plan. http://www.cms.gov/medicare-coverage-database/staticpages/icd-9-code-lookup.aspx
•This link will lead to an excel version of the latest codes: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html
A 52-year-old Irish American male is discharged from the hospital. He was hospitalized for four days after a stent placement, following admission from the emergency room with angina symptoms. This patient presented to the emergency room with four hours of crushing chest pain. He was short of breath with exertion and diaphoretic. The patient thought he was having a heart attack and was afraid to come to the hospital. The symptoms lasted for four days before the patient sought help. The patient had been suffering from similar symptoms for the past six months but thought that he just out of shape. It was worse upon admission to the hospital. Prior to this, the symptoms disappeared with rest.
His symptoms were relieved in the emergency department with medication and he was transferred to the cardiac floor for catheterization.
The patient’s symptoms were highly debilitating upon his admission to the emergency department.
Prior to his admission to the hospital for this event, the patient was not very active because of his angina symptoms. The pain that he had was substernal and crushing and radiated to his neck and jaw. His symptoms resolve with rest only. He has not sought any therapeutic maneuvers.
He is currently asymptomatic and is here for a follow-up visit from his hospitalization to discuss his risk factors. The patient is still concerned that he may have other episodes of angina, even after the stent placement.
The patient has not sought care for his problems in the past. He had been treated for hypertension and high cholesterol in the past but stopped medication on his own. Besides that, he has had no other significant illnesses.
He was hospitalized for a cholecysectomy ten years ago
This patient had a baseline EKG at his doctor’s office when he was first prescribed his blood pressure medication. Otherwise he’s had no other investigations for heart disease besides his cholesterol levels checks.
Results of Laboratory Investigations Following Hospitalization
Total cholesterol – 210
Triglycerides – 250
Fasting blood sugar – 140
HgbA1c – 7.5
CXR – hyperinflation of the lungs – no infiltrate
EKG – no change from baseline.
• High blood pressure
• Type 2 diabetes
• Android obesity
• Cigarette smoker
• Positive family history
Past surgical history of Cholecysectomy, almost 10 years age without any complications.
Review of systems is otherwise negative
Tenormin XL 50 mg QD
Lipitor 10 mg QD
Glucophage – 500mg BID
Baby ASA QD
Patient is now compliant with the prescribed regimen, but wasn’t in the past. The medicines were prescribed by the physician who discharged him from the coronary care unit.
Patient has no known drug allergies
The patient is a high school graduate and a licensed carpenter and is anxious to get back to work because of finances. His income is around $50,000.00 per year. His wife is currently disabled with uncontrolled type 2 diabetes. The patient has disrupted self-efficacy because he is not sure whether he can care for his wife, who needs his help, now that he is sick. They live paycheck to paycheck and cannot afford a vacation. They have three grown-up children who have left home and do not live in the area. The patient has lived in the same city all his life. He does not participate in sports or any other physical activity. The streets of his neighborhood are not safe for exercising; the crime rate is high. There is little community socialization and most people are at the poverty level.
He is the sole bread winner in the family. His stress level is very high because of the impending bills that he needs to pay while he is not able to work. He believes that a man should be able to care for his family and be strong enough not to suffer from any illnesses himself.
The patient and his wife live in a one-bedroom apartment in an inner city, quite isolated from their community. They do not have any relatives living in the area nor do they socialize with neighbors. He has little emotional or social support. He is stressed most of the time and is now suffering from depressive symptoms such as sleeping excessively and over eating.
This patient has health insurance through the union to which he belongs, but it does not offer complete coverage of all his prescription medications. Though he goes to a clinic that is associated with the hospital, he does not always see the same primary care provider.
• Diet Habits
The patient usually eats one large meal a day after work. He skips breakfast most of the times and eats fast food for lunch. He eats few fruits and vegetables; mostly pasta and meat at home.
He feels that he got all the exercise he needed when he was a young man, and the exercise he gets as a carpenter now is sufficient to keep him healthy.
Smoking: He smokes 1 pack per day from the past 30 years
Alcohol: Does not drink
Substance Use: Denies street drug use
• WORK HABITS
He’s always been a carpenter; has no hobbies and reads at home.
He has two older brothers who are being treated for high blood pressure and type 2 diabetes. Both brothers were diagnosed with these disorders in their early forties.
Both parents are deceased; father from heart disease, and mother from breast cancer.
7. PHYSICAL EXAMINTAION
Vital Signs: BP: 160/92 left are sitting; P:60 ; R: 16; T: 98; Wt: 220#; Ht:– 70”
Lymph Nodes: None
Lungs: Decreased breath sounds throughout, no adventitious sounds
Heart: RRR without murmur
Carotids: Right bruit
Abdomen: Android obesity, WC = 44 inches
Rectum: Not examined
Extremities, Including Pulses:
Decreased pedal pulses BL with lower leg edema from ankle to mid calf.
Neurologic: Not examined
EKG: No change from baseline
Care Plan Template
Patient Initials: ______ Age: _______________ Sex: ___________
HPI (History of Present Illness):
PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations):
Significant Family History:
Social/Personal History (occupation, lifestyle—diet, exercise, substance use)
Description of Client’s Support System:
Behavioral or Nonverbal Messages:
Client Awareness of Abilities, Disease Process, Health Care Needs:
Vital Signs including BMI:
Physical Assessment Findings:
Lab Tests and Results:
Client’s Support System:
Client’s Locus of Control and Readiness to Learn:
ICD-9 Diagnoses/Client Problems:
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):