NRNP 6568 WEEK 6 Assessing, Diagnosing, and Treating Patients With Complex Conditions
Assessing, Diagnosing, and Treating Patients with Complex Conditions
Patient Information:
ED, 69 years, Male
S.
CC (chief complaint): “Fatigue, fever, and chills”
HPI: ED is a 69-year-old male who presented to the facility complaining of fever, chills, and fatigue for the past few days. ED did not take his temperature but reported feeling hot. He expressed coughing up a little phlegm, pain when taking a deep breath, and changes in his appetite. ED has been taking Tylenol with minimal relief. He has been drinking teas to break up the phlegm. ED is a non-smoker and non-drinker.
Current Medications: ED has been taking Tylenol with minimal relief. He has been drinking teas to break up the phlegm.
Allergies: ED denied food, drug, or environmental allergies.
PMHx: ED denied a history of hospitalization or surgery. His immunization is up-to-date. He received his last tetanus toxoid vaccine more than a year ago.
Soc & Substance Hx: ED is a retired teacher. He is a non-smoker and a non-drinker. He is married. He lives with his wife and a dog. His hobbies include reading and visiting new places. He uses a seat belt when driving. ED does not have a gun at home. Their home has working smoke detectors. His family is his support system.
Fam Hx: ED reports his father died of chronic hypertension. His father also had type 2 diabetes mellitus. His paternal grandfather died from lung cancer. His uncle died from substance use disorder. There is no other significant family history.
Surgical Hx: ED denied any history of surgery
Mental Hx: ED denied any history of mental health problems, including depression and anxiety.
Violence Hx: ED denied any violence concerns.
Reproductive Hx: ED denied any history of sexually transmitted infections. He also denied urgency, frequency, or dysuria.
ROS:
GENERAL: The patient reports fever, chills, and fatigue.
HEENT: Eyes: ED denies visual changes, eye drainage, or eye pain. He denies hearing loss, nasal congestion, sneezing, sore throat, or runny nose.
SKIN: ED denies skin rash or skin itchiness
CARDIOVASCULAR: ED reports chest pain on inspiration. He denies palpitations, chest pressure, or discomfort.
RESPIRATORY: ED reports a productive cough with no shortness of breath
GASTROINTESTINAL: ED reports changes in his appetite. He denies nausea, vomiting, diarrhea, or constipation.
GENITOURINARY: ED denies burning on urination, urinary frequency, or urgency.
NEUROLOGICAL: ED denies headaches, dizziness, ataxia, or numbness. There is no change in his bladder or bowel control.
MUSCULOSKELETAL: ED denies joint pain or stiffness.
HEMATOLOGIC: ED denied anemia or easy bleeding.
LYMPHATICS: ED denied lymphadenopathy or a history of splenectomy.
PSYCHIATRIC: ED denies a history of anxiety or depression.
ENDOCRINOLOGIC: ED denies heat or cold intolerance, polyuria, or polydipsia
REPRODUCTIVE: ED denies penile discharge.
ALLERGIES: ED denies asthma, rhinitis, or allergic reactions
O.
Physical exam:
Vitals: BP 130/80, P 84, R 14, T103.2, SPO2 94%
Respiratory: The patient is not in visible respiratory distress. There is no nasal flaring. Auscultation reveals decreased rales and rhonchi, which are more pronounced in the left lower lung fields. There is increased dullness and fremitus to percussion. A chest x-ray reveals left lower lobe consolidation.
Cardiovascular: There is no cyanosis or lower limb edema. Auscultation reveals normal heart rhythm with no murmurs or skipped beats.
Diagnostic results: A chest x-ray was ordered. It revealed left lower lobe consolidation. A sputum culture and sensitivity should be ordered. This will help determine the bacteria associated with ED’s respiratory problem. It would also guide treatment decisions.
A.
Differential Diagnoses:
Pneumonia: Pneumonia is ED’s primary diagnosis. Pneumonia is an infection of the lung parenchyma caused by bacteria, fungi, or viruses. Patients present to the hospital complaining of malaise, fever, chills, myalgias, cough, and loss of appetite (Jain et al., 2024). Physical examination findings seen in these patients include tachycardia, tachypnea, decreased bronchial breath sounds, egophony, tactile fremitus, crackles, and dullness on percussion. Radiological evaluation through chest X-rays would reveal lung consolidation (Aliberti et al., 2021; Niederman & Torres, 2022). Physical examination, radiological, and subjective assessment findings confirm pneumonia diagnosis. For example, there is left lower lobe consolidation, dullness on percussion, and malaise.
Tuberculosis: Tuberculosis is ED’s secondary diagnosis. Tuberculosis is a respiratory tract infection caused by Mycobacterium tuberculosis. Patients present to the hospital complaining of fever, cough, weight loss, malaise, and night sweats. Sputum culture is the gold approach to TB diagnosis (Natarajan et al., 2020; Tobin & Tristram, 2024). However, it is the least likely diagnosis for ED because of the absence of night sweats and unintentional weight loss.
Chronic obstructive pulmonary disease (COPD): COPD is a respiratory tract infection characterized by airflow limitation to the lungs. Recurrent exposure to noxious substances causes airway inflammation and structural lung changes. COPD is commonly seen in patients with cigarette smoking. Patients experience symptoms, including cough, dyspnea, and sputum production (Agarwal et al., 2024; Ritchie & Wedzicha, 2020; Stolz et al., 2022). COPD is the least likely diagnosis due to the absence of a smoking history and symptoms such as dyspnea.
A chest x-ray was performed. It revealed left lower lobe consolidation. Laboratory investigations, including sputum and blood culture, microscopy, lymphocyte, and blood counts should be ordered. A C-reactive protein test should also be performed to differentiate between bacterial and viral pneumonia. The patient was prescribed oral doxycycline 500 mg BD for five days and oral Tylenol 1 g thrice daily as needed for pain. The patient was educated on the importance of treatment adherence, infection prevention, and signs of worsening disease status that should be reported (Jain et al., 2024). A follow-up visit was scheduled after two weeks to assess treatment response.
Health promotion and disease prevention strategies such as emphasizing the importance of flu vaccination were considered. ED was educated on the significance of utilizing screening services, including prostate cancer, hypertension, and diabetes for timely diagnoses and treatment. ED was also educated on the importance of healthy dietary practices, engaging in active physical activity, and minimizing exposure to environmental allergens for his optimal health (Ritchie & Wedzicha, 2020).
The reflection also is included in this section. I learned from this case study the benefits of a comprehensive patient assessment. Practitioners should perform detailed subjective and objective assessments to develop accurate diagnoses and appropriate treatment plans. For example, they should not rely on subjective findings alone but obtain objective data through physical examination, laboratory investigations, and diagnostic studies. I will use the knowledge gained to develop patient-centered care plans that optimize outcomes.
References
Agarwal, A. K., Raja, A., & Brown, B. D. (2024). Chronic Obstructive Pulmonary Disease. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK559281/
Aliberti, S., Cruz, C. S. D., Amati, F., Sotgiu, G., & Restrepo, M. I. (2021). Community-acquired pneumonia. The Lancet, 398(10303), 906–919. https://doi.org/10.1016/S0140-6736(21)00630-9
Jain, V., Vashisht, R., Yilmaz, G., & Bhardwaj, A. (2024). Pneumonia Pathology. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK526116/
Natarajan, A., Beena, P. M., Devnikar, A. V., & Mali, S. (2020). A systemic review on tuberculosis. Indian Journal of Tuberculosis, 67(3), 295–311. https://doi.org/10.1016/j.ijtb.2020.02.005
Niederman, M. S., & Torres, A. (2022). Severe community-acquired pneumonia. European Respiratory Review, 31(166). https://doi.org/10.1183/16000617.0123-2022
Ritchie, A. I., & Wedzicha, J. A. (2020). Definition, Causes, Pathogenesis, and Consequences of Chronic Obstructive Pulmonary Disease Exacerbations. Clinics in Chest Medicine, 41(3), 421–438. https://doi.org/10.1016/j.ccm.2020.06.007
Stolz, D., Mkorombindo, T., Schumann, D. M., Agusti, A., Ash, S. Y., Bafadhel, M., Bai, C., Chalmers, J. D., Criner, G. J., Dharmage, S. C., Franssen, F. M. E., Frey, U., Han, M., Hansel, N. N., Hawkins, N. M., Kalhan, R., Konigshoff, M., Ko, F. W., Parekh, T. M., … Dransfield, M. T. (2022). Towards the elimination of chronic obstructive pulmonary disease: A Lancet Commission. The Lancet, 400(10356), 921–972. https://doi.org/10.1016/S0140-6736(22)01273-9
Tobin, E. H., & Tristram, D. (2024). Tuberculosis. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK441916/
CLICK HERE TO ORDER A PLAGIARISM-FREE PAPER
Assessing, Diagnosing, and Treating Patients With Complex Conditions
For this Assignment, you will be assigned a complex patient case study with conditions related to any of the topics covered in Weeks 4–6. This includes cardiovascular, pulmonary, gastrointestinal, renal, musculoskeletal, and neurological conditions.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
Learning Resources
Required Readings
- Leik, M. T. C. (2021). Family nurse practitioner certification intensive review (4th ed.). Springer Publishing Company.
- Ch. 12, Nervous System Review
- Ch. 14, Musculoskeletal System Review
- Buppert, C. (2021). Nurse practitioner’s business practice and legal guide (7th ed.). Jones & Bartlett.
- “Musculoskeletal Examination” (pp. 197–198)
- “Neurological Examination” (pp. 198–199)
Note: The textbook listed below is from NRNP 6531. Review the chapters assigned in this textbook as needed to refresh your knowledge.
- Buttaro, T. M., Polgar-Bailey, P., Sandberg-Cook, J., & Trybulski, J. (2021). Primary care: Interprofessional collaborative practice (6th ed.). Elsevier.
- Ch. 154, Ankle and Foot Pain
- Ch. 155, Bone Lesions: Neoplasms and Tumor Mimickers
- Ch. 156, Bursitis
- Ch. 157, Fibromyalgia and Myofascial Pain Syndrome
- Ch. 158, Gout
- Ch. 159, Septic Arthritis
- Ch. 160, Low Back Pain
- Ch. 161, Hip Pain
- Ch. 162, Knee Pain
- Ch. 163, Metabolic Bone Disease: Osteoporosis and Paget Disease of the Bone
- Ch. 164, Neck Pain
- Ch. 165, Osteoarthritis
- Ch. 166, Osteomyelitis
- Ch. 167, Shoulder Pain
- Ch. 168, Sprains, Strains, and Fractures
- Ch. 169, Elbow Pain
- Ch. 170, Hand and Wrist Pain
- Ch. 171, Amyotrophic Lateral Sclerosis
- Ch. 172, Bell’s Palsy
- Ch. 173, Cerebrovascular Events
- Ch. 174, Dementia
- Ch. 175, Dizziness and Vertigo
- Ch. 176, Guillain-Barré Syndrome
- Ch. 177, Headache
- Ch. 178, Infections of the Central Nervous System
- Ch. 179, Movement Disorders and Essential Tremor
- Ch. 180, Multiple Sclerosis
- Ch. 181, Parkinson Disease
- Ch. 182, Seizure Disorder
- Ch. 183, Trigeminal Neuralgia
- Ch. 184, Intracranial Tumors
- Ch. 195, Polymyalgia Rheumatica and Giant Cell Arteritis
- Ch. 196, Raynaud’s Phenomenon
- Ch. 197, Rheumatoid Arthritis
- Ch. 198, Seronegative Spondyloarthropathies
- Ch. 199, Systemic Lupus Erythematosus
- Ch. 200, Vasculitis
Required Media
- Assessment and Management of Patients with Neurologic Problems
Dr. Nancy Lenaghan discusses the assessment and management of patients with neurological issues. (45m)
Recommended Media
- Musculoskeletal Disorders
Dr. Helene Creger discusses musculoskeletal disorders and what to look for as you assess your patient. (20m) - Neurologic Disorders
Dr. Anna Liza D. Villena discusses neurologic disorders and what to look for as you assess your patient. (46m) - Real World NP. (2019, December 16).Concussion evaluation for nurse practitioners in primary careLinks to an external site. [Video]. YouTube. https://youtu.be/Hy_6fZcqUkE
- Real World NP. (2020, April 28). Ortho in primary care: Hacks for new nurse practitionersLinks to an external site. [Video]. YouTube. https://youtu.be/kXauZY0v_nk
To Prepare:
- Review this and previous weeks’ Learning Resources as needed.
- Review the case study provided by your Instructor. Based on the provided patient information, think about the health history you would need to collect from the patient.
- Consider what physical exams and diagnostic tests would be appropriate in order to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis.
- Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
- Consider each patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
- Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with their condition(s).
The Assignment:
Use the Focused SOAP Note Template to address the following:
- Subjective: What details are provided regarding the patient’s personal and medical history?
- Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues.
- Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?
- Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
- Reflection notes: Describe your “aha!” moments from analyzing this case.
By Day 7
Submit your focused SOAP note.
submission information
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
- To submit your completed assignment, save your Assignment as WK6Assgn_LastName_Firstinitial
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
Rubric
NRNP_6568_Week6_Assignment_Rubric
| Criteria | Ratings | Pts | ||||
|---|---|---|---|---|---|---|
| This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned. In the Subjective section, provide: • Chief complaint• History of present illness (HPI) • Current medications• Allergies• Patient medical history (PMHx) • Review of systems |
|
10 pts | ||||
| This criterion is linked to a Learning OutcomeIn the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses |
|
10 pts | ||||
| This criterion is linked to a Learning OutcomeIn the Assessment section, provide: • At least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case. |
|
25 pts | ||||
| This criterion is linked to a Learning OutcomeIn the Plan section, provide: • A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors. • Reflections on the case describing insights or lessons learned. |
|
30 pts | ||||
| This criterion is linked to a Learning OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that 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. |
|
10 pts | ||||
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and proper punctuation |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/narrative in-text citations, and reference list. |
|
5 pts | ||||
| Total Points: 100 | ||||||
24/7 Nursing Help Online – Fast, Reliable, and Expert-Approved. From NCLEX prep to clinical advice, get instant nursing help from licensed professionals. Trusted by students and nurses worldwide.