Hx heart murmur icd 10

Case Study And Care Plan

Order Instructions: Throughout this course, you were provided case studies that focused on cardiovascular, pulmonary, genitourinary, and musculoskeletal disorders. You will pick one of these cases to analyze and create a comprehensive care plan for acute/chronic care, disease prevention, and health promotion for that patient and disorder. Your care plan should be based on current best practices and supported with citations from current literature, such as systematic reviews, published practice guidelines, standards of care from specialty organizations, and other research based resources. In addition, you will provide a detailed scientific rationale that justifies the inclusion of this evidence in your plan. Your paper should adhere to APA format for title page, headings, citations, and references. Criteria: •Case Study Evaluation (Answer all below) --Analyze the disorder addressing the following elements: pathophysiology, signs/symptoms, progression trajectory, diagnostic testing, and treatment options. -- Differentiate the disorder from normal development. -- Discuss the physical and psychological demands the disorder places on the patient and family. -- Explain the key concepts that must be shared with the patient and family to achieve optimal disorder management and outcomes. -- Identify key interdisciplinary team personnel needed and how this team will provide care to achieve optimal disorder management and outcomes. -- Interpret facilitators and barriers to optimal disorder management and outcomes. --- Describe strategies to overcome the identified barriers. Care Plan Synthesis -- Design a comprehensive and holistic recognition and planning for the disorder. -- Address how the patient’s socio-cultural background can potentially impact optimal management and outcomes. -- Demonstrate an evidence-based approach to address key issues identified in the case study. -- Formulate a comprehensive but tailored approach to disorder management. You will select one of the case studies that you previously submitted and develop a teaching plan. Please reviewing the grading criteria below. It is helpful to add the topic headings (from above) in your paper to make sure that you have addressed the requested items. CASE STUDY A 65-year-old Caucasian female presents with a chief complaint of cough for two weeks. She has been complaining of dry cough since the past two weeks and low grade fever that started two days ago, and was as high as 101 orally. She has had a decreased appetite but no nausea and vomiting. The cough occurs during the night and she needs to sit up in a chair to be able to breathe easier. The cough is mainly dry, rarely productive. She had been prescribed inhalers in the past; they have been helpful but she does not use them on a routine basis. She has been prescribed antibiotics in the past as well and that seems to help when she is acutely ill. She has been suffering from shortness of breath for the past two weeks following any kind of activity mainly because of the dry cough. She thinks it’s possible that there’s some problem with her “heart.” She is also complaining of slight sore throat, especially in the morning and feels she may have lung cancer. The patient’s symptoms have been worsening over the past two days. She has had similar episodes in the past. The last was three months ago when she had to go to the emergency room and they told her that she needed to be hospitalized. She declined hospitalization at that time and was treated and released. She says they gave her antibiotics and an inhaler before discharging her. She mentioned that though it took some time to feel better, there was gradual improvement in her condition following that treatment. According to her, this is the worst episode that she can remember. She’s very concerned today that she could have pneumonia and might require hospitalization. She is seeking medical attention today because of the fever and prolonged nature of her illness. PMH Though she has been treated for this problem in the past with antibiotics and inhalers, she has not been hospitalized. The patient had a chest investigation the last time she had this problem. She states that she did not have pneumonia but did have “emphysema.” The healthcare professionals wanted to do pulmonary function tests, but she declined. X-ray results: Hyperinflation of both lungs with an increased AP diameter. There is evidence of emphysema. . She states that she had asthma as a child and is a cigarette smoker. She also had a hysterectomy way back in 1970s. Besides these, she has no known chronic medical problems. Shortness of breath with activity. No diaphoresis. She has had a fever. No nausea and vomiting. Denies chest pressure sensation with physical activity. No palpitations. MEDICATIONS The patient does not take any prescription medicines. She takes occasional over-the- counter Tylenol for pain. Tylenol 650 mg, 2 PO as needed. She is allergic to sulfa drugs that cause a rash SOCIAL HISTORY The patient has been widowed for 20 years. She is receiving an annual pension of $40,000.00 and has some money that she has saved in the bank. She has a high school diploma and owns her house. Though she has little disposable income, her finances are essentially stable. She has little knowledge of community resources that are at her disposal. She has a primary care provider, whom she sees three to four times every year for a physical examination. The physician is very busy and does not spend much time with her. She has insurance but it does not cover all her prescription medications. She relies on a lot on samples. She has two grown-up daughters who live in the nearby community. They are both in their forties and are alive and well. The patient would like her daughters to be more involved in her life, but she is not sure how to approach them about this. The patient’s perception of self-efficacy has been declining over the past ten years. She feels that she could be feeling depressed because she does not get out of the house very often and this depression is only getting worse with each passing year. The patient has very low level of day-to-day stress. However, she realizes that her depressive symptoms may be causing some of her physical symptoms. She goes to church and has some contacts there. She sees her daughters once a month. These people are her support system, but she has no one to talk to on a routine basis. HABITS She has a healthy diet and her dietary intake is adequate. The patient has positive health beliefs and knows that she should be doing more to maintain a healthy lifestyle. She does not get adequate exercise because of her shortness of breath. She enjoys visiting her physician. Smoking: She has smoked one pack per day for 40 years. Alcohol: She denies alcohol use Substance Use: She denies any street drug use WORK HABITS She has always been a hairdresser; is retired now. She goes to church and occasionally attends some of their functions. Her hobbies include sewing. She is from the United States and lives in a suburban setting. Crime rate in her locality is low with easy access to public transportation. There are a variety of community groups, but she is not aware of these resources. FAMILY HISTORY Her two older sisters are alive and well, one with osteoporosis and one with breast cancer. Her 75-year-old sister was diagnosed with osteoporosis at the age of 55. Her 72- year-old sister was diagnosed with breast cancer at 60 years of age. PHYSICAL EXAMINATION Vital Signs: BP: 130/72 left arm sitting regular cuff; T: 101 po; P: 100 and regular; R: 20, non-labored; Wt: 130#; Ht: 55”. HEENT: White material on the buccal mucosa; does not wipe off with tongue blade. Lymph Nodes: None Lungs: Decreased breath sounds, dull to percussion right lower lobe. End expiratory wheeze in right lower lobe. No rales or rhonchi. Increased anterior-posterior diameter to chest wall. Heart: RRR without murmur Carotids: No bruits Abdomen: Benign Rectum: Not examined Genital/Pelvic: Not examined Extremities, Including Pulses: 2+ pulses throughout, no edema Neurologic: Not examined LAB RESULTS/RADIOLOGICAL STUDIES/EKG INTERPRETATION CBC- WBCs 15, 000 with + left shift Pulse oximeter reading: SAO2: 98% Radiological Studies CXR – Same as X-ray EKG Normal sinus rhythm PAPER summitted: Plan of Care Patient: 65-year-old, Caucasian female Subjective Data Client Complaints “I have a dry cough, low grade fever, and sore throat.” Present Illness: Patient complaining of having a dry cough for two weeks; reports that two days ago she started experiencing a fever, max 101F. Patient complains that the cough occurs at night and forces her to sit up to breathe. The sore throat occurs mostly in the morning. Past Medical History History of asthma as a child which has since resolved. Patient has had a similar episode in the past that were treated with antibiotics and inhalers, but refused to be hospitalized. In her previous visit, a chest exam was conducted and emphysema was reported to be the likely diagnosis although no pulmonary tests were done to confirm the diagnosis. Currently, the patient is not on any prescribed medications and only takes Tylenol for pain as needed. The patient’s chest x-ray showed no pneumonia the last time, but the findings were consistent with emphysema. Patient refused to do pulmonary function test on the previous episode. Surgical history is non-contributory and includes hysterectomy. Medication: 650 mg of Tylenol, 2 PO daily as needed for pain. Allergies/Reactions: Sulfa drugs which causes a rash. Family History Patient is widowed, though has two older sisters, ages 72 and 75 years of age. The youngest is suffering has breast cancer that was diagnosed at age 60 and the oldest has osteoporosis that was diagnosed at age 55. Two daughters, both in their forties, alive and well. Social/Personal History Patient is widowed, the past 20 years, receives $40,000 annually from a pension and has insurance, although does not cover her prescription medications. There is limited information about readily available community resources. The patient reports she eats a balanced diet but she is unable to get adequate amounts of exercise due to her dyspnea. She reports that she has been smoking a pack of cigarettes daily for 40 years. She denies any alcohol or substance abuse. Client’s Support System: Patient has two daughters who live in a nearby community that she sees on a monthly basis but who are not very involved in her healthcare. She is also involved in her local church community activities. Behavioral or Nonverbal Messages: The patient states that her health is declining, and she has been feeling depressed the last ten years because she does not get out of the house very often. Client’s Disease Process with Health Care Needs: She is not informed about the disease process, partially due to her limited educational background, being only a high school graduate. She does appear to understand that she is sick which has prompted her to eat a more balanced and healthy diet. She reports doing physical exercises which are of great significance in patients who have similar symptoms; however, she has been hindered by her shortness of breath. Client’s Readiness to Learn: Client expresses some depression due to her desire to have her daughters be more involved in her life. Patient is willing to learn and will require additional education on the risks and management of her disease. A referral to home care will be made after discharge for nursing to further educate her about her disease process and a medical social worker for community resources to assist her with medication assistance due to her limited income. Objective Data: Vital Signs: Blood Pressure: 130/72, Temp: 101, Pulse: 100 and regular; Resp: 20, non-labored; Physical Assessment: HEENT: White significant material on the buccal mucosa; which does not wipe off with a tongue blade. Lungs: Bilateral breath sounds diminished. Right lower lobe percussion is dull with wheezing present. No rhonchi or rales detected. Patient’s AP diameter to chest wall ratio is increased. Heart: Patient’s heart has a regular heart rate and rhythm. No bruits heard in the carotids Abdomen: Benign Genital/Pelvic: Not examined Extremities: Pulses: 2+ pulses throughout. No edema noted. Neurologic: Not examined Labs/Radiological Studies: CBC: WBCs 15, 000 with left shift CXR: Increased AP diameter with hyper-inflation of bilateral lungs with evidence of emphysema. EKG: Normal sinus rhythm ICD-10 Diagnoses/Client Problems: Sepsis, unspecified organism A41.9 (ICD 10 code) Viral pneumonia, unspecified J12.9 (ICD 10 code) Pulmonary emphysema J43.0 (ICD 10 code) COPD with (acute) exacerbation J44.1 (ICD 10 code) Tobacco use Z72.0 (ICD 10 code) Shortness of breath. R06.02 (ICD 10 code) Cough R05 (ICD 10 code) Fever, unspecified R50.9 (ICD 10 code) History of asthma Adjustment disorder with mixed anxiety and depressed mood F43.23 (ICD 10 code) Family hx of breast cancer Z80.3 (ICD 10 code0 Family hx of osteoporosis Z82.62 (ICD 10 code) Encounter for screening for osteoporosis Z13.820 (ICD 10 code) Advanced Practice Nursing Intervention Plan Therapeutic interventions: Admit patient to the Intensive Care Unit to be closely monitored due to sepsis as evidenced by her elevated white count with a left side. The sepsis is most likely due to a right lower lobe pneumonia as well as an acute COPD exacerbation. Obtain sputum for culture and sensitivity. In the interim, will start Ceftriaxone 1gram IV every 24 hours and Ertapenem 1-gram IV every 24 hours which are broad spectrum antibiotics (“Infectious disease,” 2016). When culture returns then antibiotics can be adjusted to pathogen. Duration of therapy will be for a minimum of five days and patient should remain afebrile for 48-72 hours before antibiotic therapy is discontinued (“Infectious disease,” 2016). The empiric therapy is used, when the organism is unknown, which means the doctor is responsible of choosing which antibiotic is likely to work based on the patient's age, health, and severity of the illness (“Pneumonia,” 2016). Community-acquired pneumonia are often caused by S. pneumoniae – a gram-positive bacterium that usually responds to antibiotics known as beta-lactams as well as to macrolides (“Pneumonia,” 2016). Also, the resistant strains of S. pneumoniae are increasingly common and may respond to fluoroquinolones’ or to ketolides. Serial CBC’s to monitor white count daily until normalized. Blood cultures x 2 from different sites, prior to initiation of antibiotics. Will also obtain baseline ABGs to monitor any improvement/decompensation that may occur during hospitalization (Pneumonia, 2016). Will also order respiratory therapy for chest PT and hand held nebulizers with albuterol 0.83% 2.5cc/3ml every four hours around the clock for first 72 hours then decrease to every 4 hours while awake. Lorazepam 0.5mg BID po as needed for anxiety Nicoderm 21mcg patch daily transdermal. Follow up Plans after hospital discharge: Levaquin 750 mg po for ten days Follow up in one week after hospital discharge for repeat chest x-ray and follow up on the patient’s smoking cessation. Education on smoking cessation should be a part of every routine evaluation and the patient should be offered smoking cessation programs that will assist them (Hong, Lin & Wan, 2016). Refer to pulmonologist for pulmonary function test and ongoing treatment of patient’s COPD. Furthermore, interdisciplinary collaboration will be of great importance in ensuring that the patient achieves desirable outcomes. Sessions should be arranged with the patient and a visiting nutritionist who will counsel on proper nutrition. This is because in acute stages of emphysema patients may lose weight whereas those at chronic stages are advised to take foods that will increase their weight (Hong, Lin & Wan, 2016). Counselors will also advise the patient about smoking cessation. It is imperative for patients to understand that smoking is the leading risk factor of emphysema. Patients with respiratory diseases are encouraged to adhere to follow-up care with health care providers to assess the patient’s results, side effects, and effectiveness of the care interventions. Depression screening using the PHQ-9, if positive for depression, then should add an antidepressant and refer to a psychologist for counseling. Referral for pulmonary rehabilitation with the goals of decreasing respiratory symptoms, improving quality of life, increasing the patient’s physical and emotional quality of life (Hong, Lin & Wan, 2016). The pulmonary rehabilitation team usually consist of a physician, occupational therapist, respiratory therapist, physical therapist, and a nutritionist (Hong, Lin & Wan, 2016). Community resources: a.) Patient education: Refer to local smoking cessation programs b.) Order home health care for medication and disease management education as well as overall respiratory status monitoring. One of the most important interventions that Heslop et al., (2013) reports is that emphysema cannot be cured but its symptoms can be managed through a number of pharmacological interventions. For instance, bronchodilators salbutamol will be prescribed to facilitate breathing by opening up the airway, inhaled steroids such as bethamesone aid in reducing lung inflammation while antibiotics are essential in managing infection of the pulmonary system which results in emphysema (Heslop, 2013). Pulmonary rehabilitation techniques should be recommended to train the patient about some breathing exercises. Research by Hong et al., (2016) has indicated that engaging in slight physical activities reduces breathlessness and improves a patient’s exercise tolerance. PRofessor feedback: Great diagnoses list. I think it may be bacterial pneumonia but sputum for C&S is indicated. You can code pneumonia without indicating which type it is. I am not sure she has sepsis. Remember she does not want to be admitted in the past. Try to treat as an outpatient. She also needs inhalers and an oral steroid for her breathing. She also has leukoplakia which is pertinent. Please see my notes below. This is a very common scenario in clinical. The patient has exacerbation of COPD and most likely pneumonia. The improper use of inhalers can lead to the development of oral thrush or oral candidiasis Diagnosis: Additional diagnoses could include: Obesity, borderline hypertension (teach self-monitoring if continues to have elevated BP), family history breast cancer: order mammogram, family history of osteoporosis: order bone density and order Calcium with Vitamin D as indicated. Also, pleural effusion, fever, cough, and orthopnea can all be coded. Also, evaluate depression with a PHQ-9 and add an antidepressant as indicated. Teach patient that it may take 2 weeks for the medication to work Follow up visit 1 to 2 weeks. Interventions: I would teach the following: Use albuterol inhaler first to open up the airways, followed by the symbicort inhaler. Rinse mouth after using the symbicort (steroid) to prevent thrush development. Nystatin suspension for thrush. I would also put her on oral steroids like a Medrol dose pack. She really needs some relief of the SOB. If she is on oral steroids I would not use ibuprophen (Motrin) for fever as this combination may lead to a GI bleed. Also the lung dullness with percussion indicates pleural effusion which can be helped by the oral steroids and antibiotic. Teach Tylenol dose ceiling. Throat lozenges prn sore throat May want to teach purse lipped breathing. Teach to elevate head on pillows and not lie flat to promote lung expansion.