57-year-old male presents to the clinic with a 3-day history of increasing shortness of breath and productive cough of clear sputum. The patient denies fever or chest pain. The pat
nursing case study
By Wednesday, for your initial post, review the assigned case study and post your response on the discussion board. Use the attached document or make a copy of the SOAPNote google doc template Links to an external site.to create your response to post.
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Case study #1 COPD exacerbation
HPI: 57-year-old male presents to the clinic with a 3-day history of increasing shortness of breath and productive cough of clear sputum. The patient denies fever or chest pain. The patient states he has been using his albuterol inhaler every 2-3 hours. The patient has a 40-year pack history of smoking
Current medications
?? Symbicort 160/4.5, two inhalations twice daily.
?? Albuterol 90 mcg 1-2 puffs inhaled every 4-6 hours prn cough or shortness ofbreathObjective:
?? BP – 138/84, Pulse 92, Respirations 24, Temp: 98.2 Oxygen saturation 92%
?? Height: 5 ft. 10 in., Weight 185 lbs.
?? Neck – No swelling, Thyroid is non-tender and non-enlarged.
?? Cardiovascular S1S2, RRR no m/r/g, no JVD, no carotid bruits, borderline tachycardia
?? Lungs – bilateral wheezing, rhonchi in left base, some use of accessory muscles
?? Skin – No rashes, skin warm and dry, no erythematous areas
?? Extremities – No edema, cyanosis or clubbingLab and x-ray results
?? CBC with elevated hemoglobin, otherwise normal
?? Chest x-ray without pneumonia with diaphragmatic flattening Assessment:
?? COPD exacerbation
?? Tobacco abuse/dependenceAddress the following questions:
Select Drug and Dosage (as written on prescription e.g. bid) MSN.E1. P1.L
Analyzes Biochemical Process MSN.E8.P1.H
Evaluates Cost MSN.E1. P3.L
Evaluates Ethical /Cultural Implications MSN.E1. P4.L
Identifies Adverse drug reactions MSN.E1.P4.L
Identifies (check if there is not an adverse reaction) interactions with othermedications MSN.E1.P4.L
Case Study #2 Asthma
HPI: 19-year-old female with a history of moderate persistent asthma. She was previously well-controlled on her medications but has been out for the last month. She does not remember what the medications were. She notices increased shortness of breath with activity and a cough at night. She does have her albuterol rescue inhaler and is using this at least once a day. She has no other health concerns. She is on oral contraceptive pills, and her LMP was two weeks ago and normal
Assessment: Moderate persistent asthma
Based on current guidelines, what medications would be prescribed?
?? Select Drug and Dosage (as written on prescription e.g. bid) MSN.E1. P1.L
?? Analyzes Biochemical Process MSN.E8.P1.H
?? Evaluates Cost MSN.E1. P3.L
?? Evaluates Ethical /Cultural Implications MSN.E1. P4.L
?? Identifies Adverse drug reactions MSN.E1.P4.L
?? Identifies (check if there is not an adverse reaction) interactions with othermedications MSN.E1.P4.LCase Study #3 Allergiesa 47-year-old female presents to the clinic with increased sneezing, rhinorrhea with nasal obstruction. Additionally, she complains of pruritus of the nose and palate. The patient has no history of asthma. She has tried over-the-counter medications with no relief. No known drug allergiesAssessment: Allergic rhinitis
What medication (s) would you prescribe?
?? Select Drug and Dosage (as written on prescription e.g. bid) MSN.E1. P1.L
?? Analyzes Biochemical Process MSN.E8.P1.H
?? Evaluates Cost MSN.E1. P3.L
?? Evaluates Ethical /Cultural Implications MSN.E1. P4.L
?? Identifies Adverse drug reactions MSN.E1.P4.L
?? Identifies (check if there is not an adverse reaction) interactions with othermedications MSN.E1.P4.L
Discuss medication management of children less than 2.Case Study #4 Smoking Cessationa 42-year-old male presents to the clinic for assistance with smoking cessation. The patient states that his son is 12, caught him trying to smoke one of his cigarettes, and has decided he needs to quit. The patient has a 35-year pack history of tobacco use. Currently, the patient is smoking two packs per day. What medication would you prescribe?
?? Select Drug and Dosage (as written on prescription e.g. bid) MSN.E1. P1.L
?? Analyzes Biochemical Process MSN.E8.P1.H
?? Evaluates Cost MSN.E1. P3.L
?? Evaluates Ethical /Cultural Implications MSN.E1. P4.L
?? Identifies Adverse drug reactions MSN.E1.P4.L
?? Identifies (check if there is not an adverse reaction) interactions with othermedications MSN.E1.P4.L
Requirements: Use the soapnote template
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