Advanced Nursing Practice.
1. Provide a bulleted list of your learning points from the clinical case you analyzed this week and the salient features of what you have envisioned for patient education in your care plan. List key points about the patient’s presenting diagnoses, how you determined these, what diagnostic tests you ordered to confirm your diagnoses, and, most importantly, what you learned about patient education for gastrointestinal system based on your research. Week 3: Gastroenterology Clinical Case HPI A 60-year-old Italian male presents with acute abdominal pain. He is a retired schoolteacher and still does some teaching on the side. He is complaining of acute onset of umbilical pain that started last evening after eating. He is experiencing a gnawing hunger pain in the umbilical area. The pain is more diffuse now and he feels nauseous, but there is no vomiting. He believes he had fever last night because he felt very warm and sweaty. His symptoms subsided after he sat up for a few hours on a chair, but he is not sure how it went away. The patient has been having these symptoms for the past 24 hours. He has had similar symptoms in the past, but it was not as bad as this. The pace of illness was worse last night and is much better now. In the past, the symptoms would last only an hour or two and resolve spontaneously. In terms of severity, the pain experienced last night, during the œattack, was a ten. Today, it is a seven. He was awake last night and the pain has been bothering him for the past 24 hours. Last night, the pain was more localized in the periumbilical region. It is more diffuse now. The pain does not radiate to the back; it is mainly generalized in the abdomen now and less intense from what it was last night. He has also been having some heartburn-like symptoms for the past two weeks. The symptoms increased after eating. The heartburn would resolve spontaneously within a few hours and sometimes it was relieved after he took some OTC antacids. The patient thinks he is having a heart attack. The worsening of his symptoms has made him seek medical care today. PMH The patient is being treated for hypercholesterolemia, hypertension, and gout. He goes to his primary care provider every three to four months for a routine checkup. The patient had œstomach problems as a young man but he is not sure of the diagnosis that was back then, but nothing else. He had an appendectomy 20 years ago, without any complications. He has been using a lot of non steroidal anti-inflammatory drugs (NSAIDs) to control his gout symptoms. Besides these, the patient has had no significant illnesses. The patient states that he has always had a œqueasy stomach and has had no other workups to date for the problem. He knows that he has some type of heartburn problem, but is treating it with only over-the-counter medications and has had no further investigations. ROS Intermittent heartburn symptoms for a few weeks, nausea. No vomiting. No blood in the stool. MEDICATIONS Indocin 50 mg Q 6 hours PRN gout symptoms Zocor 20 mg QD Propranolol 50mg BID The patient is not compliant with the prescribed regimen because he is concerned about the side effects of the medication. However, he seems to be over using Indocin as he has been experiencing symptoms of gout for the past one month. He is also trying alternative therapy such as, Saint John’s wort because he thinks he is suffering from depression. He has been taking three capsules three times a day since last month, but has not noted any difference in his symptoms. ALLERGIES/REACTIONS He has no known drug allergies. SOCIAL HISTORY He is a retired schoolteacher and still does some teaching on the side. He is living off a state teachers’ pension. His wife continues to work in a local grocery store. They are getting by but do not always have enough money to go traveling. He has a master’s degree in education. Together, they make $50,000.00 per year. The patient has access to a primary care provider and sees him three to four times per year. He has a health insurance coverage including prescription cover. His wife has osteoarthritis of both knees and hips. This limits her ability to be active. The patient would like to be more active but he is having problems with gout recently. Both husband and wife would like to be more active but don’t know if that will be possible, considering the pain that they are in. They have two grown-up children”a son and a daughter”living outside the home, both alive and well. This patient is very concerned about his symptoms and wondering whether he is having a heart attack, because his father died at the same age. His wife is equally concerned. The patient feels that he has had a good life and does not want it to end early. He does not have any undue stress and is hoping that something can be done to treat him. He feels that the medical community should be able to cure him. He does not feel the need to change his lifestyle to be healthier. His support systems include his wife and some of the people that he used to work with, in the school district. He still meets them occasionally. He is not suffering from social isolation and would like to somehow become more involved in the community, because he thinks it may help him cure his symptoms of depression. Though the patient gets anxious very easily, he does not like to show it. He walks one or two days per week. He knows he needs to do more, but his pain is a detriment. He likes to go and meet his primary care provider, but sees it more as a social event. HABITS Smoking: Non-smoker Alcohol: He drinks wine every night, sometimes to excess (4 to 5 glasses) Substance abuse: Denies use of drugs DIET HABITS His wife tries to make a healthy meal at home, but he finds himself eating fast food frequently. FAMILY HISTORY He has two older brothers. They are alive, but both have high blood pressure and high cholesterol. They developed these medical problems in their early fifties. There is a significant family history of gout throughout. The patient does not have any specific hobbies but likes to work around the house. The patient is originally from United States. He and his wife live in a residential community. There are some resources at their disposal along with community support groups, but they don’t access everything. Overall, the community is safe in terms of crime. PHYSICAL EXAMINATION Vital Signs: BP right arm sitting 175/70; T: 99 po; P: 64 regular; R: 18 and non-labored HEENT: Within normal limits Lymph Nodes: None palpated Lungs: Clear to auscultation Heart: RRR without murmur Carotids: No bruits Abdomen: + BS in all quadrants. Resonant to percussion throughout. Sharp pain with palpation at the epigastric region, radiating to the back. No HSM. No peritoneal signs. Rectum: Stool light brown and heme negative Genital/Pelvic: Not examined Extremities, Including Pulses: 2+ pulses throughout, not edema Neurologic: Not examined Lab Results/ Radiological Studies/ EKG Interpretation CBC: within normal limits LFTs: within normal limits H. pylori: Positive Amylase & Lipase: within normal limits Radiological Studies Abdominal ultrasound: Gall bladder and liver are normal EKG Interpretation EKG: Normal sinus rhythm Grading Criteria Maximum Points Review provided a bulleted list of learning points from the clinical case and the salient features of patient education. 4 Included key points about patient’s presenting diagnoses, how learner arrived at each diagnosis, and the rationale behind suggesting the diagnostic tests. 4 Listed learner’s understanding of patient education for gastrointestinal care gathered from research. 4 Total 12