CHIEF COMPLAINT: Shortness of Breath and cough

Subjective: Pt presents with complaints of shortness of breath and productive cough. Pt relates he is coughing up thick green sputum with occasional bloody sputum. Pt relates that he has increased shortness of breath with walking. Patient relates that he is also short of breath at rest. Pt also relates that he has had some chills and sweats and felt like he may have a fever. He states that he has taken Tylenol for those symptoms.

Objective: Temperature 100.9, Respiratory rate 20, Heart rate 82, Blood pressure right arm 128/70, Oxygen saturation 89% on room air, Weight 210 pounds, EKG shows normal sinus rhythm, Chest radiograph

Assessment: Skin is warm and moist. Thorax is symmetrical with diminished breath sounds with rales and expiratory wheezes throughout, negative for rhonchi. Wet productive cough noted during exam. Heart is regular sinus rhythm with rate of 82. Good S1, S2; negative S3 or S4 and negative for murmur. Abdomen protuberant with normoactive bowel sounds auscultated in all four quadrants. No pedal edema noted. 2+ dorsalis pedis pulses bilaterally. Neurologic: Patient is awake, alert and oriented to person, place and time. Chest radiograph shows infiltrate in the right middle lobe.

Priority diagnosis includes 1. Pneumonia 2. Myocardial Infarction 3. Pulmonary embolism 4. Congestive Heart Failure 5. Asthma

1. Pneumonia: The patient presents with productive cough and shortness of breath with exertion. Patient has elevated temperature and low oxygen saturations along with diminished breath sounds, rales and expiratory wheezes which are all consistent symptoms with community acquired pneumonia. (Lynn, 2017). Chest radiograph shows right middle lobe infiltrate which is also consistent with pneumonia. (Kaysin and Viera, 2016).
2. Myocardial Infarction: The patient presents with shortness of breath and low oxygen saturations. Pt states that his shortness of breath is worse with exertion but is present at rest also. Dyspnea is a frequent associated symptom with MI. (Lawesson, Thylen, Ericsson, Swahn, Isaksson and Angerud, 2018). The patient did have an EKG completed that revealed a normal sinus rhythm at a rate of 80 with no obvious signs of ectopy. Evaluation of troponin level would assist in ruling out MI as a diagnosis for this patient. (Berliner, Schneider, Welte and Bauersachs, 2016).
3. Pulmonary Embolism: Dyspnea is the primary symptom for patients with PE. (Garcia-Sanz, Pena-Alvarez, Lopez-Landeiro, Bermo-Dominguez, Fonturbel and Gonzalex-Barcala, 2014). Onset of dyspnea with PE is typically sudden and further history for this patient related to onset of symptoms. Evaluation of any extremity pain and swelling, D-dimer or chest angiography would also assist in determining if this was a more likely diagnosis. (Berliner, Schneider, Welte and Bauersachs, 2016).
4. Congestive Heart Failure: Dyspnea is also a common symptom with congestive heart failure. Fatigue, diminished exercise tolerance and fluid retention are also common symptoms of CHF. (Berliner, Schneider, Welte and Bauersachs, 2016). The patient has rales noted upon auscultation which could be consistent with congestive heart failure however coupled with the remainder of the exam including productive cough with thick green sputum and fever, CHF would not be the primary diagnosis. Further evaluation of extremities of abdomen and extremities for signs of fluid retention would be indicated as well as labs such as BNP.
5. Asthma: The patient has expiratory wheezes and shortness of breath which are both consistent with asthma; however the patient also has fever and productive cough which are not consistent asthma symptoms. (Huether and McCance, 2017).

Plan: Not indicated

References

Arcangelo, V. P., Peterson, A. M., Wilbur, V. & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Berliner, D., Schneider, N., Welte, T., & Bauersachs, J. (2016). The Differential Diagnosis of Dyspnea. Deutsches Aerzteblatt International, 113(49), 834. doi:10.3238/arztebl.2016.0834

Debasis, D., & David C., H. (2009). Chest X-ray manifestations of pneumonia. Surgery Oxford, (10), 453. doi:10.1016/j.mpsur.2009.08.006

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

García-Sanz, M., Pena-Álvarez, C., López-Landeiro, P., Bermo-Domínguez, A., Fontúrbel, T., & González-Barcala, F. (2014). Original article: Symptoms, location and prognosis of pulmonary embolism. Revista Portuguesa De Pneumologia, 20194-199. doi:10.1016/j.rppneu.2013.09.006

Post 2

S:

Chief Complaint: “I am having chest pain at this time”

History of Present Illness: Pleasant, Caucasian male experiencing an acute onset of sharp, constant chest pain when taking a deep breath. Denies any alleviating factors. Yesterday his wife noticed his RT leg was edematous with erythema, denies any injury. Recently he returned from a vacation with an 8-hour plane ride. The patient was not asked if his pain radiated or if he had nausea or dizziness.

Past Medical History: Denies taking any medications. Allergies, surgeries, past medical conditions “not provided.” History of cancer or deep vein thrombosis not provided.

Social History: Married

Review of symptoms:

General: Feels short of breath when taking a deep breath, also having sharp lower RT rib pain.

Cardiovascular: Experiencing tachycardia. Peripheral edema started yesterday in RT lower leg.

Pulmonary: Reports having sharp pain when taking a deep breath with no relief measures noted. Complains of dyspnea with productive hemoptysis cough this morning.

        Gastrointestinal: “not provided.”

O:

VS: BP 148/88 RT arm; P 112 and irregular; R 32 and labored; T 97.9 orally; Pulse Ox 90% on RA; His current weight is stable at 210 pounds.

General: Well-nourished, a well developed Caucasian male who is alert and cooperative. He is a good historian and answers questions appropriately. Patient sitting upright at the side of the cot appears anxious with labored breathing. Guarding noted in the anterior, distal RT rib area.

Cardiovascular: Skin is pallor, cool and diaphoretic. Heart rate is tachycardic. S1 and S2 irregular with no S3, S4, or murmur auscultated. RT calf with erythema, 2+ edema, warmth, and tender with palpation. LT leg with no edema, tenderness, or erythema noted. Bilateral 2+ dorsalis pedis pulse. Telemetry showing a sinus arrhythmia.

Gastrointestinal: Protuberant abdomen with active bowels x 4 quadrants.

Pulmonary: LT Lung clear to auscultation, RT middle and lower lobes with diminished breath sounds. No rales, rhonchi, or wheezing auscultated. Respirations labored. Respiratory excursion symmetrical.

Diagnostic results: CXR, ECG, venous doppler studies and ultrasound for DVT, V/Q scan, CT of the chest, labs- sputum culture, cardiac enzymes. Telemetry.

A:

Differential Diagnosis:

1.) Pulmonary Embolism

2.) Pneumonia

3.) Lung Cancer

4.) Myocardial Infarction

5.) Cardiac Arrythmia

P: “not required”

Evidence and Justification of Differential Diagnosis and Diagnostic Tests

Gruettner J. et al. (2015) report the Wells risk score assesses the history of a previous

DVT or PE in a patient. Assessment of tachycardia, recent surgeries or immobilization,

observation of DVT signs, an alternative diagnosis less likely than pulmonary embolism,

hemoptysis, and cancer are gathered. Each area is assigned a score and the calculated total score

interprets the probability of having a pulmonary embolism. The patient calculated score

indicated a pulmonary embolism even though the history of cancer was unknown.

The diagnostic test of a CT angiography was found to be successful in the diagnosis of a

pulmonary embolism with Gruettner J. et al. (2015) research. The D-dimer, ABG, EKG, and

computed tomography showed little value in the diagnosis (Gruettner J. et al., 2015).

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016) indicate pneumonia causes the

This week, complete the Aquifer case titled “Case #3: 65-year-old female with insomnia – Mrs. Gomez”

Apply information from the Aquifer Case Study to answer the following discussion questions:

· Discuss the Mrs. Gomez’s history that would be pertinent to her difficulty sleeping. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.

· Describe the physical exam and diagnostic tools to be used for Mrs. Gomez. Are there any additional you would have liked to be included that were not?

· Please list 3 differential diagnoses for Mrs. Gomez and explain why you chose them. What was your final diagnosis and how did you make the determination?

· What plan of care will Mrs. Gomez be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?

You are doing an eight-week clerkship in a family medicine practice. Christina, the medical assistant, hands you the progress note for the next patient, which identifies the patient as Mrs. Gomez, “a 65-year-old woman who is here today reporting that she can’t sleep.”

Dr. Lee, your preceptor, fills you in: “Mrs. Gomez has been a patient here for several years. Difficulty sleeping is a new issue for her. Her past medical history is significant for hypertension and diabetes. Generally, she has been doing well, although I notice that her last hemoglobin A1c has climbed to 8.7%.”

Question

What are common causes of insomnia in the elderly?

SUBMIT

References

Yaremchuk K. Sleep disorders in the elderly. Clin Geriatr Med. 2018 34(2):205-216. doi: 10.1016/j.cger.2018.01.008.

CONTINUE

DIAGNOSES

FINDINGS

NOTES

BOOKMARKS

Common causes of insomnia in the elderly:

1. Environmental problems
2. Drugs/alcohol/caffeine
3. Sleep apnea
4. Parasomnias: restless leg syndrome/periodic leg movements/REM sleep behavior disorder
5. Disturbances in the sleep-wake cycle
6. Psychiatric disorders, primarily depression and anxiety
7. Symptomatic cardiorespiratory disease (asthma/chronic obstructive pulmonary disease/congestive heart failure)
8. Pain or pruritus
9. Gastroesophageal reflux disease (GERD)
10. Hyperthyroidism
11. Advanced sleep phase syndrome (ASPS)

TEACHING POINT

Common Causes of Insomnia in the Elderly

Issues that may lead to an environment that is not conducive to sleep.

· Specific examples include: noise or uncomfortable bedding.

· You can teach the patient sleep hygiene techniques that will increase the likelihood of a restful night’s sleep.

Question the use of prescription, over-the-counter, alternative, and recreational drugs that might be affecting sleep.

Patients should be counseled to avoid caffeine and alcohol for four to six hours before bedtime.

Sleep apnea is common in the elderly, occurring in 20% to 70% of elderly patients.

Obstruction of breathing results in frequent arousal that the patient is typically not aware of; however, a bed partner or family member may report loud snoring or cessation of breathing during sleep.

In restless leg syndrome, the patient experiences an irresistible urge to move the legs, often accompanied by uncomfortable sensations.

In periodic leg movement and REM sleep behavior disorder, the patient experiences involuntary leg movements while falling asleep and during sleep respectively.

As in sleep apnea, the sleeper is often unaware of these behaviors and a bed partner or family member may need to be asked about these movements.

Disturbances in the sleep-wake cycle include jet lag and shift work.

Patients with depression and anxiety commonly present with insomnia.

Any patient presenting with insomnia should be screened for these disorders.

Patients with shortness of breath due to cardiorespiratory disorders often report that these symptoms keep them awake.

Pain or pruritus may keep patients awake at night.

Those with GERD may report heartburn, throat pain, or breathing problems.

These patients may also have trouble identifying what awakens them.

Detailed questioning may be needed to elicit the symptoms of this disorder.

Elderly patients with hyperthyroidism frequently do not present with typical symptoms such as tachycardia or weight loss, and laboratory studies may be required to detect this problem.

Circadian rhythms change, with older adults tending to get sleepy earlier in the night. In advanced sleep phase syndrome (ASPS), this has progressed to the point where the patient becomes drowsy at 6 to 7 p.m. If they go to sleep at this hour, they sleep a normal seven to eight hours, waking at 3 or 4 a.m. However, if they try to stay up later, their advanced sleep/wake rhythm still causes them to awaken at 3 or 4 a.m. This can be difficult to distiguish from insomnia.

SLEEP HYGIENE

TEACHING

Dr. Lee tells you, “Poor sleeping habits can also cause insomnia. Here is a handout on sleep hygiene. For some patients, simply correcting their sleep habits by following these tips will correct their quality of sleep.”

You review the handout.

TEACHING POINT

Good Sleep Hygiene

Your Personal Habits

· Fix a bedtime and an awakening time. The body “gets used to” falling asleep at a certain time, but only if this is relatively fixed. Even if you are retired or not working, this is an essential component of good sleeping habits.

· Avoid napping during the day. If you nap throughout the day, it is no wonder that you will not be able to sleep at night. The late afternoon for most people is a “sleepy time.” Many people will take a nap at that time. This is generally not a bad thing to do, provided you limit the nap to 30 to 45 minutes and can sleep well at night.

· Avoid alcohol four to six hours before bedtime. Many people believe that alcohol helps them sleep. While alcohol has an immediate sleep-inducing effect, a few hours later as the alcohol levels in the blood start to fall, there is a stimulant or wake-up effect.

· Avoid caffeine four to six hours before bedtime. This includes caffeinated beverages such as coffee, tea and many sodas, as well as chocolate, so be careful.

· Avoid heavy, spicy, or sugary foods four to six hours before bedtime. These can affect your ability to stay asleep.

· Exercise regularly, but not right before bed. Regular exercise, particularly in the afternoon, can help deepen sleep. Strenuous exercise within the two hours before bedtime, however, can decrease your ability to fall asleep.

Your Sleeping Environment

· Use comfortable bedding. Uncomfortable bedding can prevent good sleep. Evaluate whether or not this is a source of your problem, and make appropriate changes.

· Find a comfortable temperature setting for sleeping and keep the room well ventilated. If your bedroom is too cold or too hot, it can keep you awake. A cool (not cold) bedroom is often the most conducive to sleep.

· Block out all distracting noise, and eliminate as much light as possible.

· Reserve the bed for sleep and sex. Don’t use the bed as an office, workroom or recreation room. Let your body “know” that the bed is associated with sleeping.

Getting Ready For Bed

· Try a light snack before bed. Warm milk and foods high in the amino acid tryptophan, such as bananas, may help you to sleep.

· Practice relaxation techniques before bed. Relaxation techniques such as yoga, deep breathing and others may help relieve anxiety and reduce muscle tension.

· Don’t take your worries to bed. Leave your worries about job, school, daily life, etc., behind when you go to bed. Some people find it useful to assign a “worry period” during the evening or late afternoon to deal with these issues.

· Establish a pre-sleep ritual. Pre-sleep rituals, such as a warm bath or a few minutes of reading, can help you sleep.

· Get into your favorite sleeping position. If you don’t fall asleep within 15 to 30 minutes, get up, go into another room, and read until sleepy.

Getting Up in the Middle of the Night

Most people wake up one or two times per night for various reasons. If you find that you get up in the middle of night and cannot get back to sleep within 15 to 20 minutes, then do not remain in the bed “trying hard” to sleep. Get out of bed. Leave the bedroom. Read, have a light snack, do some quiet activity, or take a bath. You will generally find that you can get back to sleep 20 minutes or so later. Do not perform challenging or engaging activity such as office work, housework, etc. Do not watch television.

A Word About Television

Many people fall asleep with the television on in their room. This is often a bad idea. Television is a very engaging medium that tends to keep people up. We generally recommend that the television not be in the bedroom. At the appropriate bedtime, the TV should be turned off and the patient should go to bed. This also applies to computers, tablets and smart phones. Some people find that the radio helps them go to sleep. Since radio is a less engaging medium than TV, this is probably a good

EACHING POINT

Treatments for Primary Insomnia in the Elderly

Of the behavioral treatments, many of which may be of some assistance in the elderly, only sleep restriction/sleep compression therapy and multi-component cognitive-behavioral therapy have met evidence-based criteria for efficacy.

Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I is recommended as the first choice for most patients with insomnia. CBT-I combines different behavioral treatments, resulting in improvements lasting up to two years. Recent guidelines recommend CBT-I as the first-line therapy for insomnia in adults. Examples include:

· Sleep restriction therapy: The patient is told to reduce his or her sleep/in-bed time to the average number of hours the patient has actually been able to sleep over the last two weeks (as opposed to the number of hours spent in bed (awake plus asleep)). As sleep efficiency increases, time allowed in bed is increased gradually by 15- to 20-minute increments approximately once every five days (if improvement is sustained) until the individual’s optimal sleep time is obtained.

· Sleep compression therapy: The patient is counseled to decrease the amount of time spent in bed gradually to match total sleep time rather than making an immediate substantial change.

Pharmacological Therapy

All drugs for the treatment of insomnia can be associated with side effects – particularly prolonged sedation and dizziness – that can result in the risk of injuries and confusion.

Preferred agents:

Class

Agents

Comments

Benzodiazepine Receptor Agonists

zolpidem (Ambien)

eszopiclone (Lunesta)

Improved sleep onset latency, total sleep time, and wake after sleep onset

Tricyclic Antidepressants

doxepin 3-6 mg

Doxepin only suggested agent in this class

Orexin Receptor Antagonist

suvorexant (Belsomra)

Improved sleep-onset and/or sleep-maintenance insomnia.

Benzodiazepines can be effective but have more complications and the additional risk of addiction.

Antihistamines, antidepressants (in the absence of depression), anticonvulsants, and antipsychotics are associated with more risks than benefits in older adults.

Combining CBT-I and pharmacological therapy can be helpful in some patients.

The evidence base for exercise as a treatment for insomnia is less extensive. Despite this, there are many other reasons to encourage regular physical activity in the elderly, assuming there are no other contraindications to such activity.

References

Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;165(2):125-33. DOI: 10.7326/M15-2175

CONTINUE

DIAGNOSES

FINDINGS

NOTES

BOOKMARKS

After discussing these potential causes of insomnia with Dr. Lee, you feel prepared to talk with Mrs. Gomez. You knock on the exam room door and enter to find a pleasant-appearing Latina who is accompanied by her daughter, Silvia. You introduce yourself and ask if you may ask her a few questions, to which she agrees.

“What brings you to the clinic today?”

“I’m just so tired lately. I just can’t seem to sleep.”

“Tell me more about this.”

“Well, for the last six months I can’t sleep for more than a couple of hours before I wake up,” Mrs. Gomez tells you.

On further questioning, Mrs. Gomez denies any discomfort such as pain or breathing problems disturbing her sleep. She denies any snoring, apneic spells (a period of time during which breathing stops or is markedly reduced), or physical restlessness during sleep. Her daughter agrees that she has not seen these problems. She rarely consumes alcohol or caffeine.

When you ask if anything like noise or an uncomfortable sleeping environment might be bothering her, she replies that this is not a problem – but her daughter interjects: “Yes, in fact Mom’s waking up the rest of us, walking around and turning on the TV. My husband and I both work. So we all need our rest. Mom came to live with us last year after Dad passed away. We’re her only family around here and we thought we should help her.”

CONTINUE

DIAGNOSES

FINDINGS

NOTES

BOOKMARKS

You tell Mrs. Gomez,

“I’m sorry to hear about your husband.”

“Yes, we were married for 30 years. This has been a difficult time for me.”

“Do you find that you feel sad most of the time?”

“Of course I am sad when I think about my husband and how much I miss him. But I wouldn’t say that I’m sad most of the time.”

Silvia states, “But Mom, you spend most of your time just moping around the house.” Turning to you she elaborates, “She seems to be in slow motion most of the time. She doesn’t even go to church anymore. She used to go three to four times a week. She used to read all the time, and she doesn’t do that anymore either.”

Mrs. Gomez explains, “I haven’t been reading as much as I used to because I can’t seem to focus and I end up reading the same page over and over.” She goes on to say, “And I don’t seem to have any energy to do anything. I’m not even able to help out around the house. I feel bad about that; I should be helping out more. I seem to spend a lot of time just watching TV and eating junk food.”

CONTINUE

DIAGNOSES

FINDINGS

NOTES

BOOKMARKS

I’m not familiar with that product, but I’ll mention it to Dr. Lee. I’m glad you brought it up. It’s important that your doctors know about everything you are taking, whether it’s prescription medication or not. I’m sorry nothing seems to be helping you sleep. We’ll get to the bottom of this together.”

You turn your attention to taking Mrs. Gomez’s past medical history. You learn:

Problem list:

· Hypercholesterolemia

· Type 2 diabetes

· Hypertension

Surgical history:

· Cholecystectomy

· Hysterectomy (due to fibroids)

Medications:

For diabetes:

· Glyburide (10 mg daily)

· Metformin (1,000 mg bid)

For blood pressure:

· Methyldopa (250 mg bid)

· Lisinopril (10 mg daily)

For cholesterol:

· Atorvastatin (80 mg daily)

For CHD prophylaxis:

· Aspirin 81 mg daily

For osteoporosis prevention:

· Calcium citrate with vitamin D (600mg/400 IU bid)

Diphenhydramine is her only over-the-counter medication, and she is taking no traditional or herbal medications beyond the zapote tea.

Social History

She does not smoke, and drinks only small amounts of alcohol on holidays.

References

Kemp C, Rasbridge LA. Refugee and Immigrant Health: A Handbook for Health Professionals. Cambridge, UK. Cambridge University Press; 2004.

CONTINUE

DIAGNOSES

FINDINGS

NOTES

BOOKMARKS

Given what you have heard from Mrs. Gomez and her daughter, especially

· her inability to focus,

· her lack of energy,

· the sense that she is in slow motion,

· she has stopped doing activities she previously enjoyed,

You are concerned that her insomnia may be due to depression. Depression may stem from environmental stressors such as her husband’s death and her loss of independence along with a primary neurochemical imbalance. Her depression also could be caused by another medical condition.

Medical Conditions Associated with Depression

A number of diseases either cause depressive symptoms or have depression as a comorbidity at higher rates than would be normally expected.

In looking for the causes and associations of depression, first consider the common conditions. Then think about the very serious diseases that you don’t want to miss. Beyond that, there’s a very wide range of diagnoses that can look like depression:

Hypothyroidism:

About 5% of the U.S. population has hypothyroidism. Checking the level of thyroid stimulating hormone (TSH) would help make the diagnosis. Hypothyroidism can be treated with thyroid-replacement medications such as triiodothyronine (T3) and/or levothyroxine (T4). Once TSH levels are returned to the normal range, the symptoms of depression often subside.

Parkinson disease:

Up to 60% of people with this disorder experience mild or moderate depressive symptoms. Although several reports have shown a link between depressive symptoms and Parkinson disease, it is unclear whether one causes the other or if both may arise from some common mechanism. A recent study has indicated that depressive symptoms are an early feature of Parkinson disease, preceding the characteristic movement problems seen in Parkinson such as tremor and rigid muscles. Therefore, people with signs of depression who start to develop movement problems should be promptly evaluated to rule out a diagnosis of Parkinson disease.

Dementia:

Dementia and depression may be difficult to differentiate, as people with either disorder are frequently passive or unresponsive, and they may appear slow, confused, or forgetful. The Mini-Mental State Examination (MMSE) is useful to assess cognitive skills in people with suspected dementia. (The MMSE examines orientation, memory, and attention, as well as the ability to name objects, follow verbal and written commands, write a sentence spontaneously, and copy a complex shape.) Early and accurate diagnosis of dementia is important for patients and their families because it allows early treatment of symptoms. For people with other progressive dementia, early diagnosis may allow them to plan for the future while they can still help to make decisions. These people also may benefit from drug treatment.

Hypertension (C) and asthma (E) have not been specifically linked to higher rates of depression.

Some other diseases that have been linked to depression include:

· Endocrine disease (Addison disease, diabetes, Cushing syndrome, hypoglycemia, hyperparathyroidism)

· Acquired immunodeficiency syndrome

· Cardiovascular disease (myocardial infarction, angina)

· Cancer (particularly of the pancreas)

· Cerebral arteriosclerosis, cerebral infarction

· Electrolyte and renal abnormalities

· Folate, cobalamin and thiamine deficiencies

· Hepatitis

· Intracranial tumors

· Multiple sclerosis

· Porphyria

· Rheumatologic disease (rheumatoid arthritis, systemic lupus erythematosus, temporal arteritis)

· Syphilis

· Temporal lobe epilepsy

· Huntington’s Disease

· Chronic pain

· EVIEW OF SYSTEMS

· HISTORY

· Keeping in mind the disorders associated with depression, you elicit a review of systems from Mrs. Gomez to help discover what these indicate regarding her underlying illness.

· Constitutional: Mrs. Gomez has gained about 10 lbs in the last six months. She denies fevers or dizziness. This makes you less concerned about cancer or other systemic illness.

· Respiratory: No shortness of breath, making cardio-respiratory disease less likely.

· Cardiac: No chest pains, palpitations or edema, decreasing the likelihood of cardiovascular disease.

· Gastrointestinal: No nausea, changes in bowel habits, hematochezia or melena. This makes you less concerned about gastrointestinal cancer or occult blood loss leading to anemia.

· Endocrinologic: No polydipsia or polyuria, decreasing the likelihood of poorly controlled diabetes.

· Neurologic: No acute neurologic changes or tremors. Her daughter confirms that patient has been alert, oriented and has had no episodes of confusion. So you are now less concerned about cerebral infarction, intracranial tumors, multiple sclerosis, and Parkinson disease.

· Urologic: Normally urinates one to two times at night.

· Once you have completed your review of systems, you excuse yourself from the room for a moment while Mrs. Gomez changes into a gown.

· CONTINUE

Tutor MUST have a good command of the English language

Please read all the instructions and requirements

Sources need to be less than five years old and journal/scholarly articles.

No textbook or direct quotes

All the Rubric requirements listed MUST be met.

***I have attached the DPI Project Milestone: 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project Assignment with the instructor’s corrections/comments. This needs to be revised as well meeting the instructor’s expectations.

Details:

Empirical research is the foundation of scholarly research and scholarly writing. An empirical article is defined as one that reports actual results of a research study. An empirical article includes a description of the study, an introduction, a research question, an explanation of the study’s methodology, a presentation of the results of the study, and a conclusion that discusses the results and suggests topics for further study.

As you search the library for scholarly research, you should limit your search to identify empirical articles. (You can use the “Empirical Research Checklist” from DNP-801 to assist in this determination.) After finding an empirical study, begin to assess the validity of the conclusion by determining if the conclusion answers the proposed research question and if the methodology is appropriate.

As you move forward in your doctoral journey, you will read research papers that will require you to assess the validity of the studies in question. To accomplish this, qualitative assessments about the research must be made by comparing, contrasting, and synthesizing what the research says.

In this assignment, you will continue to develop the skill of writing, by reviewing 15 research articles associated with your chosen topic and using the content to identify at least five major concepts and subthemes related to your topic.

General Requirements:

Use the following information to ensure successful completion of this assignment:

Use the “Empirical Research Checklist” to assist in the determination of empirical articles.

Use the “Research Article Chart” to provide a summary review of each component of your assignment.

Doctoral learners are required to use APA style for their writing assignments. The APA Style Guide is located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.

Directions:

Part 1: Selection of 15 Articles

Select 15 empirical articles related to your PICOT question. Use the “Empirical Research Checklist” worksheet to ensure that each article you select meets all of the established criteria. At least one article must demonstrate a quantitative methodology.

Clinical/PICOT Question:

In Patients > 65 years of age with central line catheters, how does staff training of key personnel and reinforcement of central line catheter hub hygiene after its insertion, along with the apt cleansing of the insertion site, reduce the incidence of CLABSIs (Central Line Associated Blood-stream Infections) at a level two trauma facility compared to standard care over a one-month period?

P: Patients > 65 years of age with a central line

I: Staff training and reinforcement of central catheter, hub hygiene

C: Compared to standard care

O: Reduce the incidence of CLABSIs (Central Line Associated Blood-stream Infections)

T: A period of one-month

Part 2: Research Article Chart

Using the articles acquired in Part 1, provide a summary review of each component using the “Research Article Chart” template.

Part 3: Synthesis of Research Studies

Based upon your review of the 15 research articles, identify at least five major concepts that relate to your project topic, and three subthemes related to each concept.

Using the information from the completed “Research Article Chart,” and the major concepts and subthemes you have identified, write a 2,000-3,000 word paper that synthesizes the content of the 15 research studies.

Summarize each major concept and focus on providing a detailed synthesis of the three identified subthemes that support that concept by addressing the following.

Introduction of the identified subtheme

Summary of the research questions posed by the studies

Summary of the sample populations used

Summary of the limitations of the studies

Summary of the conclusion and recommendations for further research

Select a health care organization in your community to conduct an interview with an appropriate risk management employee. The organization can be your current employer, or a different health care facility in your community. Acute care, urgent care, assisted living facilities, and community/public health clinical facilities are all ideal options to complete the requirements of this assignment. (MUST BE WITHIN MARYLAND).

Make sure to select an individual who can provide sufficient information regarding how that organization manages risk within its facility to answer the questions below.

In your interview, address the following:

Identification of the challenges the organization faces in controlling infectious diseases.

Risk management strategies used in the organization’s infection control program, along with specific examples.

How the facility’s educational risk management program addresses key professional issues, such as prevention of negligence, malpractice litigation, and vicarious liability.

Policies the facility has implemented that address managing emergency triage in high-risk areas of health care service delivery.

Strategies the facility utilizes to monitor and maintain its risk management program.

Post-interview, compose a 1,000 word summary analysis of the interview to include the questions above as well as the following elements:

A brief assessment of the organization’s risk management program, including what works well and what could work better (the pros and cons).

Action steps you would take to improve the program. Select one area and provide your rationale and possible steps required to implement your suggestion.

Cite appropriate references as needed to support your statements and rationale. MINIMUM OF 3 REFERENCES

Prepare this assignment according to the guidelines found in the APA Style Guide.

CHECK PLAGIARISM PLEASE