NURS 6550N Week 10 I-human interview

What does the pain in your head feel like? Like a headache 18. Have you had any trauma to your head at any time? Did somebody hit me? Nobody hit me. Johnny talks to me, but doesn’t hit me. 19. Has she had any trauma t ...

What does the pain in your head feel like? Like a headache 18. Have you had any trauma to your head at any time? Did somebody hit me? Nobody hit me. Johnny talks to me, but doesn’t hit me. 19. Has she had any trauma to her head? Nothing in the chart, but you should probably ask Joan. 20. When did her confusion start? About 3 weeks ago after a change in her psych medications. 21. Can you describe the nature of confusion or types of memory loss? She seems less focused and has trouble completing her tasks. You know, everyone has jobs in the home. 22. Is she taking any prescription medications? Yes, you should look at the patient record 23. Any new/recent changes in medications? Yes, Geodon (ziprasidone HCl) was added three weeks ago because her doctor felt she was experiencing more auditory hallucinations. 24. Is she having any problems with her medications? Not that I am aware of. 25. When did she last take her medications? Today 36. Do you have any difficulty urinating? ------ Who are you? 37. Do you have any of the following problems: fatigue, difficulty sleeping, unintentional weight loss/gain, fevers, night sweats? I don’t know. I’ve been feeling sleepy and my clothes are loose. 38. Do you have any problems with: itchy scalp, skin chages, moles, thinning hair, brittle nails? I don’t think so. 39. Have you noticed any breast discharge, lumps, scaly nipples, pain, swelling or redness? No 40. Do you experience chest pain discomfort or pressure, pain/pressure/dizziness with exertion or getting angry; palpitations; decreased exercise tolerance; blue/cold fingers and toes? No 41. Do you experience SOB, wheezing, difficulty catching your breath, chronic cough, sputum production? Oh, I always have a morning cough. You know, just bring up a little white stuff. I smoke. Maybe I’ll quit someday. 42. Do you have problems with nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety, bloating? I told you about my stomach. Your list is too long to remember. 43. When you urinate, have you noticed pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day/night, or any changes in frequency? Nope 44. Do you have problems with muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint swelling/redness, back pain, neck or shoulder pain, hip pain? No I’m thirsty now, can I lie down? 45. Do you have any of the following heat/cold intolerance, increased thirst, increased sweating, frequent urination, change in appetite? I am thirsty all the time. Can I get some water? 46. Have you noticed any bruising, bleeding gums, nose bleeds or other 85. How severe is your headache? I don’t know. It hurts but I can still talk to you. 86. When did your fatigue/tiredness start? ------ Why am I here? 87. When did your memory problems start? I don’t know 88. Can you describe the nature of the confusion or the types of memory loss? It’s what the staff tells me. 89. Do you have nausea/vomiting? I feel a little sick to my stomach. I have not vomited but I feel like I might. 90. When did your nausea/vomiting start? I don’t remember 91. When did her nausea/vomiting start? I don’t know. Ask her. 92. When did her cough start? I think she’s had it for years. 93. Does she have any pain or other symptoms associated with her cough? Not that she as complained of. 94. When did your cough start? It’s been a while 95. Do lung cancer, it is common to have hyponatremia with non small cell lung cancer, she has that terrible cough and stated her clothes were getting looser, weight loss, hyponatremia and CT right upper lung mass with lymph adenopathy Yes especially when the caregiver keeps telling you to ask the patient...I kept thinking COPD exacerbation and hyponatremia. It wouldn’t do a chest x-ray which I don’t understand and then I ordered a CMP and it gave me no results. I mean come ON!!!!! **Drug induced SIADH Hyponatremia in the cancer patient is usually caused by the syndrome of inappropriate antidiuretic hormone (SIADH), which develops more frequently with SCLC than with other malignancies. SIADH may be driven by ectopic production of arginine vasopressin (AVP) by tumors or by effects of anticancer and palliative medications on AVP production or action. Physical ExamSkin: Skin is warm and dry with no lesions seen. Thickness and distribution pattern typical for patient gender and age. Nails without ridging, pitting, or peeling. Normal capillary refill in fingers and toes. Quincke’s test – blanching observed HEENT: Head- No visible scaliness, edema, masses, lumps, deformities, scars, rashes, nevi or other lesions. Nontender. Normocephalic, atraumatic. Eyes- No ptosis, erythema, or swelling. Conjunctiva pink and no discharge. Sclera anicteric. No edema/redness/tenderness or lesions noted in orbital. Visual acuity 20/20 bilaterally. Ears- Normal appearing external structures. No deformities or edema. No discharge noted. Normal appearing external auditory canals. Tympanic membrane translucent, non-injected, and pinkish-gray in color. No scarring, discharge, or purulence noted. Normal landmarks. Normal mobility with insufflation. No hearing deficit. Normal Weber and Rinne tests. Nose- No discharge or polyps. No edema or tenderness over the frontal or maxillary sinuses. Mouth – Oral mucosa moist. Pale-yellow coating on tongue. Poor dentition. No unusual odor. Neck- No visible scars, deformities, or other lesions. Trachea is midline and freely mobile. No asymmetry or accessory respiratory muscle use with quiet breathing. Full cervical ROM. No meningeal signs. Thyroid WNL for size and consistency; no palpable nodules. No cervical lymphadenopathy. Normal swallowing. Thyroid moves with swallowing. Normal JVP. Breast: Normal breast exam. The breasts and nipples are non-tender. There are no masses, lumps, deformities, ulcerations, or discharge. Lymphatic: Two right supraclavicular nodes; each approximately 2 cm in diameter, firm, nonmobile, nontender. No cervical axillary, infraclavicular, or inguinal lymphadenopathy. Chest/Lungs: The chest is symmetrical and the AP diameter is normal. The excursion with respiration is symmetrical and there are no abnormal retractions or use of accessory muscles. No distension, scars, masses, or rashes. No tenderness, lumps, or masses. Normal tactile fremitus. All superficial thoracic lymph nodes are non-palpable or of normal size and consistency. The anterior lung fields are resonant. The left anterior chest and right lower chest are dull to percussion. The rest of the lung fields are resonant and are not hyper-resonant. CV: PMI is 5th ICL at MCL. GI: Abdomen is flat and symmetric with no scars, deformities, striae, or lesions. (+) Bowel Sounds in all quadrants. No pain, tenderness, masses, or pulsations. There is no guarding or rebound tenderness. No hepatosplenomegaly. Liver span normal. The spleen is not palpable. No tympany or shifting dullness. Normal girth. Osteopathic: Atraumatic. No joint swelling. No signs of DVT. No peripheral edema. No tenderness, muscular resistance, rigidity, or deformity. MS: Normal bulk and tone. No rigidity. No asymmetry or deformity of the back. No tenderness or spasm of the paraspinal muscles. No localized tenderness of the spinous processes or pelvicstructures. Non-tender to percussion. ROM is normal and equal bilaterally. Normal stability. Unable to assess strength due to patient unable to follow instructions. Vascular: Normal ABI Neuro: MMSE 30/30. CN I-XII intact. Normal balance. Patient too weak and unsteady to test gait and stance. No signs of involuntary movements. Negative Romberg. No pronator drift. All DTR (triceps, biceps, brachioradialis, knee/patella, ankle/achilles) are 2+ bilaterally. No tropia. No phoria. No latency, torsional, up/down beating, fatigable nor reversible nystagmus. Normal sensory test. Light touch, pain, temperature, vibration, and proprioception are grossly intact. GU: Normal external genitalia. No m asses or tenderness. Normal pelvic exam. Rectum: No visible fissures, induration or lesions. Normal sphincter tone. No masses or tenderness. Guaiac negative. VS: 37 F, HR 92, RR 24, O2 sat. 93% ** follow up on EKG – for prolong QT interval Follow up on renal panel UA Urine osmolality I-Human Template This term, you will be using iHuman modules as part of the clinical requirement for this course. In iHuman, you will interact with the virtual patient, collection a history, perform a physical exam, order tests, make differential diagnoses, and make a management plan. This term, the iHuman modules will be different than the last term, in case you may have heard from previous students. You will be able to order more than one round of tests, and your questions will be limited to a certain number. There will be other improvements as well that I think will enrich the experience for you. Please note that it will take a few days for everyone to receive their iHuman log in credentials. Below is the template you are required to follow EXAMPLE Week 8 I Human I-Human Template Primary Diagnosis: Diabetic Ketoacidosis (DKA) Status/Condition: Critical Code Status: Full Code Resuscitation Status Allergies: No known allergies Admit to Unit: ICU to monitor/manage tachycardia, insulin gtt, electrolyte imbalances, etc. Activity Level: Bedrest until electrolytes have been corrected and vital signs are more stable. Diet: NPO until anion gap is closed. Need to monitor for nausea/vomiting/aspiration risk IVF: -Start Levophed (Norepinephrine) 2 mcg/min and titrate to keep MAP >65 (CEUfast Inc., 2019) -Fluid resuscitation is needed considered the patient is extremely dehydrated. The vascular space needs to be repleted. -Rapid IV infusion of 1-3L 0.9% NS. Replete to raise blood pressure, keep adequate UOP, and to correct hyperglycemia (Brutsaert, 2019). **Patients will need a minimum of 3 L NS boluses over the first 5 hours of treatment (Brutsaert, 2019). -Once adequate UOP and blood pressure is stable switch to 1/2NS@75cc/hr IVF (Brutsaert, 2019). -If/when the blood glucose drops < 200mg/dL need to switch IVF to D5 ½ NS @75cc/hr (Brutsaert, 2019). Follow Up Lab tests : -Q1H blood sugar checks to maintain blood sugar 120-160 (Brutsaert, 2019). -Q1H vital signs -Lactic acid Q4H to monitor acidosis and ensure that it is titrating down (Brutsaert, 2019). -Chem panels Q4H to monitor/replete electrolytes, monitor hydration status via renal function -Repeat EKG to check for ischemic changes and ensure that tachycardia is resolving Diagnostic testing: -Order CXRAY to ensure that the patient is not being fluid overloaded. -CT scan brain if patient’s mental status declines (Brutsaert, 2019). BMP revealed: Hypernatremia, elevated BUN to Cr ratio (57)  Elevated serum Na 148  Elevated blood glucose 566  Elevated BUN 86  Elevated Cr 1.5  Elevated anion gap 30 CBC WNL EKG revealed: ST, no evidence of ischemia, left ventricle hypertrophy HbA1c: Elevated at 10.3% UA revealed:  Very pale yellow urine  >800 osmolarity  +4 urine glucose Lipid profile revealed:  Cholesterol 250  HDL 40  LDL 165  Triglycerides 200 Free water deficit = 0.5 x 101 / (148/140) -1 = 2.9LConsults: **After a 24 hour period involve a few consults to help manage the patient better and to set her up for future care -If patient is unable to tolerate PO intake after being weaned off insulin gtt will need a nutrition consult for diet recommendations (Brutsaert, 2019). -Considering this is the patient’s diagnosis of DKA and diabetes, it is imperative to get a Endocrinologist on board as well as diabetes healthway team to educate the patient about diabetes and the complications that can go along with it if not properly managed (Brutsaert, 2019). Patient Education and Health Promotion: -Keep up to date on immunizations -Educate on the importance to remain abstinent from smoking -Educate on all the risks that are associated with smoking -Educate on the importance of decreasing alcohol intake and the risks that come with prolonged use to ETOH or Tobacco abuse -Educate about diabetic neuropathy and the importance to keep feet clean and dry constantly (Kreider, 2018). -Educate patient on how to check their blood sugar and how they need to monitor it every 4H especially before meals in order to accurately give themselves the correct dose of SQ insulin. -Educate about the different types of insulin and what they are for. Discharge planning and required follow-up care: -Involve a discharge planner to help coordinate with the patient and the hospital to find health insurance so the patient can seek out the care she needs in order to manage her diabetes effectively. -Follow up with PCP for overall health in one week -Schedule first appointment with endocrinologist to learn more about diabetes and to be able to be educated on how to best manage diabetes. -Hgb A1C needs to be rechecked in 3 months (Kreider, 2018). -If symptoms return, contact endocrinologist (Kreider, 2018). -Ensure that Diabetes way healthcare team is involved in her new diagnosis of diabetes and how to count calories and carbs to better control and monitor their diabetes (Kreider, 2018). -Ensure proper handwashing -Avoid people who are ill/sick References Brutsaert, E. (2019, January). Diabetic Ketoacidosis (DKA) - Endocrine and Metabolic Disorders. Retrieved from https://www.merckmanuals.com/professional/endocrine-andmetabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/diabeticketoacidosis-dka?query=DKA#v989319CEUfast Inc. Vasoactive Drips: A guide to starting and titrating critical care drips, Adult and Pediatric. (2019, July). Retrieved from https://ceufast.com/course/vasoactive-drips-a-guide-tostarting-and-titrating-critical-care-drips-adult-and-pediatric Kreider, Kathryn Evans. (2018, September). The Journal for Nurse Practitioners, Volume 14, Issue 8, 591 - 597 (Kreider, 2018)