Patient encounter, from history to treatment plan.

Full Answer Section

  History of Present Illness: Mrs. Jones has been experiencing shortness of breath for the past few months. The shortness of breath is worse when she walks or climbs stairs. She has also been feeling tired and has lost 10 pounds in the past 2 months. Past Medical History: Hypertension, diabetes, COPD, hyperlipidemia, and osteoarthritis. Social History: Mrs. Jones is widowed and lives alone. She is retired and does not smoke or drink alcohol. Physical Examination: Mrs. Jones is a thin, frail woman in no acute distress. Her vital signs are: temperature 98.6 degrees Fahrenheit, heart rate 100 beats per minute, respiratory rate 22 breaths per minute, blood pressure 160/90 mmHg, and oxygen saturation 92% on room air. Her lungs are clear to auscultation. Her heart has a regular rate and rhythm. Her abdomen is soft, non-tender, and non-distended. Laboratory Tests: The following laboratory tests were ordered:

• Complete blood count (CBC): within normal limits
• Chemistry panel: within normal limits
• Electrocardiogram (EKG): normal sinus rhythm
• Chest X-ray: no acute abnormalities

Diagnosis: Mrs. Jones was diagnosed with heart failure. Treatment Plan: Mrs. Jones was started on a diuretic and an ACE inhibitor. She was also given education on how to manage her heart failure at home. Outcome: Mrs. Jones' shortness of breath and fatigue improved with treatment. She was able to walk and climb stairs without difficulty. She also gained back some of the weight she had lost. Discussion: This case study illustrates the importance of a comprehensive patient history and physical examination in the diagnosis of heart failure. Mrs. Jones' shortness of breath and fatigue were initially attributed to her COPD. However, the physical examination findings and laboratory tests were more consistent with heart failure. The diagnosis was confirmed with an EKG and chest X-ray. The treatment of heart failure is complex and requires a multidisciplinary approach. Mrs. Jones was started on a diuretic and an ACE inhibitor. She was also given education on how to manage her heart failure at home. With treatment, Mrs. Jones' symptoms improved and she was able to resume her normal activities. Faculty Feedback: The faculty feedback on this case study was positive. They commended me on my thorough patient history and physical examination. They also appreciated the way I presented the diagnostic findings and treatment plan. I am grateful for the opportunity to present this case study. It has helped me to solidify my knowledge of heart failure and the importance of a comprehensive patient assessment. I am confident that I will be able to use this knowledge in my future practice as an advanced practice nurse.

Sample Answer

  Patient: Mrs. Jones, a 75-year-old woman with a history of hypertension, diabetes, and chronic obstructive pulmonary disease (COPD). Chief Complaint: Mrs. Jones presents to the clinic with complaints of shortness of breath, fatigue, and weight loss.