Posted: June 14th, 2023

Intractable nausea and vomiting for the past 5 weeks

Assessing, Diagnosing, and Treating Musculoskeletal and Neurologic Disorders
Number of sources: 5
Paper instructions:
Assessing, Diagnosing, and Treating Musculoskeletal and Neurologic Disorders
Consider the example of Sue from the case study in Chapter 13 of your textbook:

Sue is a 68-year-old healthy woman with no significant medical history. She is in the office today with complaint of intractable nausea and vomiting for the past 5 weeks with an 11-pound weight loss. On review of systems she also has noted a dull, persistent headache, difficulty with concentration, and some blurred vision.
(Kennedy-Malone et al., 2019, p. 359)

Photo Credit: [Blend Images/Ariel Skelley]/[Blend Images]/Getty Images

Sue also has a notable family history of diabetes and heart attack. How would you, as an advanced practice nurse, assess, diagnose, and treat Sue? ( diagnosis with lab A1C for her Diabetes and the medication ( METFORMIN, see from the list) she has the medication for nausea )

Add anything to complete, this is a patient from the first part of the story.

What specific considerations related to the older adult population would you need to consider? ( Age, Nutrional status and other diseases when treating her to be added )
Keep these thoughts in mind as you examine this week’s case study.

Reference:
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. G. (2019). Advanced practice nursing in the care of older adults (2nd ed., p. 359). F. A. Davis.

To prepare:

Review the case study provided by your Instructor.
Reflect on the patient’s symptoms and aspects of disorders that may be present.
Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
Access the Focused SOAP Note Template in this week’s Resources.
The Assignment:

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.

medications

Xarelto Oral 20 MG 30 Tab(s) take one tab daily (C)
ANTICOAGULANTS
metFORMIN HCl Oral 500 MG 60 Tab(s) take 1 Tab(s) po twice a day
ANTIDIABETICS
Lisinopril Oral 5 MG 90 Tab(s) take one tab po daily
ANTIHYPERTENSIVES
Metoprolol Succinate ER Oral 25 MG take 1/2 tab ( 12.5 mg ) po daily
BETA BLOCKERS
Atorvastatin Calcium Oral 40 MG 90 Tab(s) Take one tablet orally every hour sleep (ANTIHYPERLIPIDEMICS)
Vitamin C Oral 500 MG 1 Cap(s) orally daily
VITAMINS(LS)Multivitamins Oral 1 Cap(s) orally daily
MULTIVITAMINS(LS)
HYDROcodone-Acetaminophen Oral 10-325 MG 1 Tab(s) orally every 4-6 hr as needed for pain
ANALGESICS – OPIOID
Furosemide Oral 40 MG 1 Tab(s) Twice Daily
DIURETICS
levETIRAcetam Oral 500 MG 1 Tab(s) Twice Daily
ANTICONVULSANTS(LS)Gabapentin Oral 600 MG 1 Tab(s) Three Times Daily
ANTICONVULSANTS

Phenergan 12.5 PO every 8 hours as needed for nausea

____________________
Subjective:
Chief Complaint: Intractable nausea and vomiting for the past 5 weeks, 11-pound weight loss, dull persistent headache, difficulty with concentration, and blurred vision.
History of Present Illness: Sue is a 68-year-old healthy woman with no significant medical history. She has a family history of diabetes and heart attack.