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NURS 680A Advanced Health/Physical Assessment Week 8 Discussion Forum

NURS 680A Advanced Health/Physical Assessment Week 8 Discussion Forum

NURS 680A Advanced Health/Physical Assessment Week 8 Discussion Forum

Complete your Week 8 discussion prompt.

This week you will complete a case study prompt and a reflection prompt.

  • Select one of the following case studies to address:
    1. A 42-year-old patient is 3 days post-op from abdominal cholecystectomy. She is currently taking only antibiotics and hydrocodone. Today she complains of left calf pain just below the knee and states it is swollen, warm, and painful to touch. She denies other symptoms, significant history, or allergies.
    2. A 66-year old woman complains of shortness of breath, numbness and heaviness of her arms when walking up the hill to her house. The pain subsides when she stops to rest.

For the case you have chosen, post in the discussion:

    • Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
    • In SOAP format, list:
      • Pertinent positive and negative information
      • Differential and working diagnosis
      • Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
    • Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
    • In your peer replies, please reply to at least one peer who chose a different case study.
  • Reflect on what you’ve learned in this course:

Sample Solution

The patient is a 42-year-old female, three days status post cholecystectomy, currently reporting the development of left lower extremity pain, warmth, and swelling. Negative for any other symptoms, pertinent medical history, and allergies. Currently taking antibiotics and hydrocodone.

Questions for Patient

Considering the symptoms can be attributed to several diagnoses, the background information pertaining to the patient being three days post-op indicates the possibility of a common post-surgical complication in the form of a clot (Evans & Ratchford, 2018). Questions I would like to ask the patient begin with the OLDCART mnemonic because it would be prudent to know the onset or when the patient noticed the swelling, redness, and pain. Likewise, the degree of pain while attempting to move the extremity, reliving factors, and characteristics. I would also like to find out if the patient is receiving any thromboembolic therapy in the sense of compression stockings or sequential compression devices, pharmacological therapy such as subcutaneous heparin or enoxaparin. Additionally, I would like to know if the hydrocodone she’s taking is effective, whether she has been experiencing fevers, chills, or malaise. Furthermore, I would ask the patient if she has any history of scraping or wounding her lower extremities, or a history of clotting disorders, as well as ask if the patient was on any form of birth control medications. Finally, I would like to know if the patient started to ambulate at all since the surgery.

Objective Data Review

Pt is day 3 post op for Cholecystectomy

Left lower extremity redness and swelling; measure circumference of both lower extremities to compare size difference. NURS 680A Advanced Health/Physical Assessment Week 8 Discussion Forum

On ABx post-op; afebrile.

Possible Homan’s test positive (If performed on assessment)

Differential Diagnoses

Working Diagnosis: Deep Vein Thrombosis

Pos Pertinent: Post operative redness, pain, and swelling of the posterior calf within 3 days of abdominal surgery, patient possibly immobile post-op.

Neg Pertinent: Uknown for vascular injury or hypercoagulability.

In the case of deep vein thrombosis, post-surgical venous stasis is a very common etiology for the formation of a deep vein clot in the lower extremities (Stone et al., 2017). Considering all of the subjective and objective data thus far, it would not be unreasonable to suspect DVT as the primary and working diagnosis for this development. Signs and symptoms for DVT coincide with the presentation noted above with the redness, swelling, and pain in the posterior calf right below the knee (Stone et al., 2017). There are quite a bit of factors involved in the potential formation of a DVT beginning with venous stasis and extending to hypercoagulability, and in the case of this patient venous stasis is the most likely culprit when recovering from a considerable surgical procedure, which can be considered as a form of trauma. Generally, the formation of a DVT is within the window of time of 3 days of bedrest or hospitalization (Evans & Ratchford, 2018).

Differential Diagnosis 1: Superficial Thrombophlebitis

Pos Pertinent: Post operative redness, pain, and swelling of the posterior calf within 3 days of surgery.

Neg Pertinent: No recent history of trauma to extremity, no reported/assessed varicose veins.

While the DVT diagnoses is more likely, it is also very likely that this indicates the formation of a superficial vein thrombus as the symptoms of pain, redness, and swelling coincide with the symptoms of a DVT (Evans & Ratchford, 2018). As mentioned above, the timeline, precipitating factors, and the objective and subjective data also contribute to the potential of this being plausible. However, considering the patient’s age and absence of pertinent medical history, as well as other unknown factors outside of the surgical procedure and the length of time since, it would not be unreasonable to consider this situation a DVT vs SVT scenario.

Differential Diagnosis 2: Cellulitis

Pos Pertinent: Swelling, pain, and redness of the lower extremity.

Neg Pertinent: Afebrile, no knowledge of elevated WBC.

Cellulitis is a fairly common bacterial infection of the skin and subcutaneous tissues, and may breakout from isolated dormant structures in the tissues in events where the immune system weakens as a result of traumatic events or a disease process (Collazos et al., 2018). The patient in the case study had just undergone surgery which can account for immune system weakening, however in light of the pertinent negatives this can be ruled out through diagnostics. The patient is already in antibiotics and afebrile as far as we know, so if anything, this is an early presentation of cellulitis with a non-systemic effect as of yet. Despite the previously discussed diagnoses being more likely, the redness, swelling, and pain are also possible symptoms of cellulitis.

Treatment Plan

Initial planning will involve diagnostics to confirm or rule out the DVT. Diagnostics prevalent for this case would a venous ultrasound to visualize the thrombus, a PT/INR and DDimer to assess for coagulability, possibly a CT and/or contrast venography if available (Stone et al., 2017). Medical management will encompass anticoagulation therapy with either UFH or LMWH with an eventual progression to an oral anticoagulant. It is also possible to plan ahead for a vena cava filter placement as a preventative measure against the progression to a pulmonary embolism (Stone et al., 2017). Additionally, the patient’s diet will need to be changed and ensure a decreased intake of vitamin K. Once the patient can be cleared, physical therapy must be initiated to get the patient up. Education will focus on prevention of venous stasis and medication regimen adherence, as well as possible complications to a DVT such as the progression to PE.

References:
  • Collazos, J., de la Fuente, B., García, A., Gómez, H., Menéndez, C., Enríquez, H., Sánchez, P., Alonso, M., López-Cruz, I., Martín-Regidor, M., Martínez-Alonso, A., Guerra, J., Artero, A., Blanes, M., de la Fuente, J., & Asensi, V. (2018). Cellulitis in adult patients: A large, multicenter, observational, prospective study of 606 episodes and analysis of the factors related to the response to treatment. PLOS ONE13(9). https://doi.org/10.1371/journal.pone.0204036
  • Evans, N. S., & Ratchford, E. V. (2018). Superficial vein thrombosis. Vascular Medicine23(2), 187–189. https://doi.org/10.1177/1358863×18755928
  • Stone, J., Hangge, P., Albadawi, H., Wallace, A., Shamoun, F., Knuttien, M. G., Naidu, S., & Oklu, R. (2017). Deep vein thrombosis: Pathogenesis, diagnosis, and Medical Management. Cardiovascular Diagnosis and Therapy7(S3). https://doi.org/10.21037/cdt.2017.09.01

Part 2 – Reflection

This course helped me in developing sharper researching skills in terms of assessing for appropriate interventions for diagnoses and supporting positive and negative pertinent data. Likewise, this course assisted me in understanding the process of progress note writing as well as its purposes. The process of collecting information from patients in the subjective and objective sense has been a challenge, but the process of learning how to do it also assisted greatly in understanding how to synthesize the gathered information into a plan of action.

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