Assignment: Nurse Practitioner
To prepare:
1. Review the case study provided by your Instructor.
2. Reflect on the patient's symptoms and aspects of disorders that may be present.
3. Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
Case study:
Mrs. L., a 68-year-old woman, presents to your office today with a complaint of feeling tired all the time and now, more recently, feeling weak and like "I can't catch my breath sometimes."
HPI: She has been healthy except for high cholesterol, managed by Lipitor. Her husband died 9 months ago, and she has attributed her fatigue to dealing with his death but realizes that she is feeling worse and not better as time passes.
No known drug allergies.
Medications: Takes only Lipitor.
Past surgical history: Appendectomy in childhood; hysterectomy for uterine myoma 10 years ago.
No significant medical history. Has two daughters living nearby.
Blood pressure (BP) 106/70 mm Hg, heart rate (HR) 98 beats/min and regular, respiratory rate 18 breaths/min and afebrile, body mass index (BMI) 22 (10-pound weight loss since death of husband).
Slender, quiet-spoken older woman appearing tired.
PE: Conjunctiva pale, mucous membranes moist. No lymphadenopathy of neck or femoral area.
Heart tachyarrhythmia with regular rate, soft midsystolic murmur. Chest (CTA), good air movement.
Abdomen soft, bowel sounds × 4.
Diagnostics:
Urine dipstick negative.
The results of a colonoscopy show a neoplasm in the colon.
Address the following in your SOAP note:
I. What additional subjective data are you seeking?
II. What additional objective data will you be assessing for?
III. What medical history would you obtain from the patient? List at least three.
IV. What tests will you order? Describe at least four lab tests.
V. What are the differential diagnoses that you are considering? Describe two.Provide at least TWO evidence-based peer-reviewed journal articles or evidenced-based guidelines, which 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.
VI. What is your plan of care? List at least two diagnostic tests you will order to evaluate the cause of her condition.
VII. Finally, include a reflection statement on the case that describes insights or lessons learned.
Format your assignment according to the give formatting requirements:
1. The answer must be double spaced, typed, using Times New Roman font (size 12), with one-inch margins on all sides.
2. The response also includes a cover page containing the title of the assignment, the course title, the student's name, and the date. The cover page is not included in the required page length.
3. Also include a reference page. The references and Citations should follow APA format. The reference page is not included in the required page length.