Advanced Nurse Practice in Reproductive Health Care
Advanced Nurse Practice in Reproductive Health Care
Episodic/Targeted SOAP Be aware
Affected person Info:
E.W., 69, Male.
S.
CC (chief grievance): I can not hear a lot of the dialogue on the tv
HPI: E.W. is a 69-year-old male affected person who presents to the well being clinic complaining of issue in listening to a lot of the dialogue on the tv. One of many members of the family who accompany him to the power complains the affected person can not hear. He continues to work in the varsity setting. His medical historical past is sort of benign. His solely medicines are aspirin 81 mg. every day, a multivitamin every day, and occasional ibuprofen for again ache. Speech is evident and coherent however tangential at occasions. He makes no uncommon motor actions and demonstrates no tics. He denies any visible or auditory hallucinations.
Present Medicines:
Aspirin 81 mg. every day
Multivitamin every day
Occasional Ibuprofen
Allergic reactions: NKDA
PMHx: Cerumen impactions faraway from each ears and again ache. Immunization data are updated.
Soc & Substance Hx: The affected person has no historical past of substance and alcohol abuse. He’s married however not sexually energetic. He lives along with his daughter and his spouse. He has labored in the printing firm for 35 years. He continues to work in faculty settings.
Fam Hx: The affected person is heterosexual however not sexually energetic. He’s married to at least one spouse and so they have a daughter. The spouse and the daughter haven’t any important medical historical past. The grandparents are deceased for no important medical historical past. The couple has no grandchildren.
Surgical Hx: No prior surgical procedures.
Psychological Hx: The affected person has no important psychological historical past, dizziness, tinnitus, or vertigo. The affected person has no historical past of despair, anxiousness, self-harm, or suicidal ideation.
Violence Hx: He has no historical past of bodily or sexual violence at house, at work, or in the group.
Reproductive Hx: His reproductive system is wholesome however he’s at present not sexually energetic. He’s a father to at least one.
ROS:
GENERAL: No unintentional weight reduction or achieve, fever, and fatigue.
HEENT: Eyes: No blurred imaginative and prescient or yellow sclera. Ears, Nostril, Throat: No listening to issue, nasal congestion, working nostril, or sore throat.
SKIN: No itching, pores and skin rashes, or lesions.
CARDIOVASCULAR: The affected person has no chest strain, edema, discomfort, ache, or palpitations.
RESPIRATORY: No respiratory difficulties, sputum, or congestion.
GASTROINTESTINAL: No diarrhea, nausea, consuming problems, blood in the stool.
GENITOURINARY: No issues, ache, or inconsistencies in urination. No historical past of urinary system sickness.
NEUROLOGICAL: No modifications in bowel, bladder management, dizziness, or ataxia. The affected person has no continual headache or numbness.
MUSCULOSKELETAL: No ache in the muscular tissues, joints, stiffness, and again.
HEMATOLOGIC: No instances of bleeding or bruising.
LYMPHATICS: The affected person has no historical past of splenectomy. No swollen nodes.
PSYCHIATRIC: The affected person has a historical past of trauma, anxiousness, stress, or despair. He was handled for dementia for 2 years however didn’t take all of the medicines or adhere to the counseling pointers.
ENDOCRINOLOGIC: The affected person has no historical past of polyuria, polydipsia, head, or sweat intolerance.
REPRODUCTIVE: The affected person is just not sexually energetic. He has been in a heterosexual marriage. No ache in the reproductive organs, or penile discharge.
ALLERGIES: No identified historical past of medicine, climate modifications, bronchial asthma, rhinitis, or eczema.
O.
Bodily examination:
Important Indicators: 118/80 P: 88 P02: 97% WT: 148 HT: 5’7”
Common: A&O * four, appears sick as a result of uninteresting face. The affected person is groomed for the clinic go to. He’s neat and hygienic and aware of the encompassing.
HEENT: Eyes: watery eyes. No issue in imaginative and prescient. Ears: No listening to issue through the dialog, the tympanic membrane is in place. Nostril: No itchy or congested nostril. Throat: No swollen tonsils.
Neck: JVD, full ROM, carotid no bruit.
Chest/Lungs: CTA AP&L, no dyspnea.
Coronary heart/Peripheral Vascular: The examination reveals no murmur or peripheral pulses +2 bilaterally, RRR, or edema.
Stomach: No irregular bowel sounds.
Genital/Rectal: Deferred.
Musculoskeletal: No irregular growth or asymmetrical motion. Power 5/5.
Neurological: DTR intact, CN II – XII intact.
Pores and skin: No pores and skin lesions, rashes, blisters, and plaques.
Diagnostic outcomes:
CXR— no important cardiopulmonary findings.
MMSE—Ms. Washington scores 18 out of 30 with major deficits in orientation, registration, consideration and calculation, and recall. The rating suggests reasonable dementia.
A.
Differential Diagnoses
Dementia – dementia is the final time period for circumstances that result in lack of reminiscence. The prognosis of dementia is as a result of MMSE rating of the affected person. The rating reveals the affected person has 18 out of 30. The affected person might be experiencing dementia that has varied signs together with restricted social abilities, forgetfulness, and restricted pondering capabilities that intervene with every day actions (Janelidze et al., 2020).
Alzheimer’s illness – Alzheimer’s illness is a progressive illness that results in reminiscence loss. The situation happens when the cell connectors die thus undermining the reminiscence capabilities (Bron et al., 2017). The situation can result in confusion.
PTSD – Put up-traumatic stress dysfunction is a situation that causes traumatic recollections and experiences. The situation is frequent amongst individuals who have recollections of traumatic occasions (Bron et al., 2017). The trauma impacts the standard of life and participation in every day actions.
P.
The therapeutic interventions for dementia embrace cholinesterase inhibitors resembling Aricept. The aim of the drug is to enhance the chemical concerned in the reminiscence and judgment features in the mind. Aricept 10mg tab bedtime is efficient (Nordström & Nordström, 2018). The affected person ought to go to the power after two weeks for additional analysis. Psychotherapy is one other intervention for the therapy of the situation (Nordström & Nordström, 2018). The affected person needs to be referred to a counselor for added interventions.
The pattern of dementia and different psychological circumstances are frequent amongst aged sufferers. One of many necessary classes is to make use of each pharmacological and psychotherapeutic interventions to handle the signs. The perfect affected person training is to encourage adherence to the therapy.
References
Bron, E. E., Smits, M., Papma, J. M., Steketee, R. M., Meijboom, R., De Groot, M., … & Klein, S. (2017). Multiparametric computer-aided differential prognosis of Alzheimer’s illness and frontotemporal dementia utilizing structural and superior MRI. European radiology, 27(eight), 3372-3382.
Janelidze, S., Mattsson, N., Palmqvist, S., Smith, R., Seashore, T. G., Serrano, G. E., … & Blennow, Ok. (2020). Plasma P-tau181 in Alzheimer’s illness: relationship to different biomarkers, differential prognosis, neuropathology and longitudinal development to Alzheimer’s dementia. Nature Drugs, 26(three), 379-386.
Nordström, A., & Nordström, P. (2018). Traumatic mind harm and the danger of dementia prognosis: A nationwide cohort research. PLoS medication, 15(1), e1002496.
