Pathophysiology.
I have attached a rubric to this. And the diagnosis I would like to use is Heart failure, which can be treated with diurectics such as Lasix
Patient is a 72 year old male here today for evaluation, and presents as a new patient to the clinic. Patient has a history of Class I Heart Failure with PMH of Hypertension, Hyperlipidemia, and MI 3 years ago with 2 stents placed and Type 2 Diabetes Mellitus. His blood sugars run around 200 average; Patient has smoked cigarettes since age 15, and has smoked 1 1/2 packs per day. He has been on short acting Beta Agonist with minimal relief. He states he has dyspnea with exertion. He had a pulmonologist, and he underwent a Pulmonary Function test 2 years ago. He states he has a chronic cough, moist and notes he has a hard time eating with his breathing. Staff is able to obtain some records from the last Pulmonary Function test that reveal his FEV 1 was 77%; He notes he cannot complete all the activities during the day without becoming very short of breath. He is retired from Steel Mill in 2005; He is allergic to codeine. He has also noted new swelling in his feet for about the last month or so, especially when he has been more active. His current medications include:
Ventolin HFA, 180 mcg, 2 puffs q4-6 hours;
Metoprolol 50 mg bid
LIsinopril 5 mg daily
Metformin 500 mg bid
Plavix 75 mg daily
He lives with his wife who is 70 yrs old and is in stable health and is a retired school teacher. They live in Rural area of Ohio. The live off of his Pension from the Mill and her pension from teaching. They have 2 grown children who live out of state but check in on the parents occasionally.
FOR THIS CASE STUDY, DO NOT ADD TO THE SCENARIO. ANSWER THE FOLLOWING QUESTIONS:
Case studies will be presented in four-to six categories. The student will develop a Differential Diagnoses for each case study based on the information provided, and document their clinical reasoning in deciding on a final diagnosis The student will document the steps taken in the decision process, additional or missing data, the decision rationale, proposed treatment plan and follow up plan for assessment of treatment plan success. In addition, include cultural considerations, References Minimum 3 to 5 Peer Reviewed Journals outside of the class materials within 5 years. APA 7th ed. Format, COVER PAGE, NO ABSTRACT, REFERENCE PAGE RUBRIC FOR GRADING AS
FOLLOWS:
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- Define the problem (s) , what pertinent health issues does the patient have Identify specifically what Health History would need to obtain (what is the Pathophysiology of her illness? )
- questions you would ask, family history, patient history, etc) Current Medications, Allergies, dose,
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- Drug class and all pertinent drug information, polypharmacy, possible drug interactions- Full Drug Review- Cytochrome P450 system, where drug metabolized, possible drug/drug interactions
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- Differential Diagnosis and support rationale why Genomic information
- Treatment plan- What additional medications might you consider for this patient? What Tests?
- Health Promotion
- Primary, Secondary or Tertiary care Cultural Considerations
- What would you expect to determine the effectiveness of the care plan?
- How would you determine if the intervention were effective to meet your objectives?
- What kind of follow up would you have with this patient
- What specialty services and/or members of the interdisciplinary team would you involve and why?
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(Case Study Format:
Here is a “general” format;
Title page/Page numbers
Case Presentation
Pathophysiology of the (illness )
Your Physical Assessment -What are you going to assess and why
Differential Diagnosis- what could it be, Evidence Based Practice -Rationale, support with EBP
Cultural Perspectives
Health Promotion – what would you teach the patient?
Treatments- both pharmacological and non pharmacological
(Include CYP 450 system)
What tests, screenings might you consider
What is your Plan of care, when would you have them f/u with provider and why?
References 3-5- All these items – you need to support with Evidence Based Practice, such as for example, Non pharmacological interventions- where did you obtain your info, citation for the source; any tests, any of the above items, support your rationale with Evidence Based Practice.
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