nursing case study and need the explanation and answer to help me learn.
Must be completed in APA essay format with references from 2018-2023. See the case study and questions attached as well as scoring guide for assessment. References must be from a medical or nursing journal.
Case Study #2 for Nurse Practitioner Students
Read the following SOAP note about an interesting case written by an NP student:
J.B. is a 3 yobm presenting with: CC: “eyelids and legs are swollen”.
HPI: One month ago, his mother noticed he had swelling of the eyelids and to both legs. He also had clear, watery nasal drainage. She thought this was an allergic reaction and took him to the local emergency dept., he was prescribed Zyrtec liquid and discharged home. There been no improvement and she feels he is getting worse. Associated signs and symptoms include weight gain, polydipsia, loss of appetite and lethargy. He has gained approx. 5lbs in 1 month. He c/o of frequent thirst and consumes 8-9 six-ounce glasses of water, juice or whole milk during the day and wakes up at night thirsty. Was eating well until the swelling started and now eats much less even when offered preferred foods such as collard greens, peas, bread, broccoli, and fruit. He is not playing as much and tires easily. No c/o (per mom) of enuresis, polyuria, dysuria, frequency, urgency, obvious hematuria, unusual color or strong odor to his urine.
Birth history: On time vaginal delivery, 40 wks gestational age. No congenital problems or abnormalities noted on newborn screening. Birth weight 7lbs 3 oz, height 19 inches.
Allergies: Motrin (swelling, edema).
Current Medications: Zyrtec syrup
Illnesses/surgeries: No history of serious illness, feeding problems or developmental delays. Had a “cold” in January 2009, resolved in 1-week w/o complications.
Tests: Routine metabolic birth screening negative at birth and 2 wks, Lead test negative at 9 months. Immunizations: Up to date: Hep B #1 at birth, #2 at 4 months and #3 at 7 months. DTap, Hib and PCV at 2 months, 4, 6 and 18 months. IPV at 2, 4 and 18 months, MMR and Varicella and 15 months.
FH: Mother 26 yobf (homemaker) alive & well, Father 23yobm (office manager) alive & well, 5yo sister positive for anomalous coronary artery-had surgery (successful) to repair anomaly in 2007 maternal grandmother and maternal aunt positive for Type II DM, Maternal grandfather died of MI in 1995, paternal grandfather positive for asthma, paternal grandmother alive & well. Ages of grandparents and aunt not know.
J.W. lives in an apartment w/ his 5yr old sister, mother, father and maternal grandmother.
SH: J.W. stays at home w/ their mother and grandmother. Sister attends kindergarten. Mother and father smoke, state they smoke outside. Denies ETOH, illicit drugs or guns are in the household. Have working smoke detectors and apartment was built in the 1990’s.
ROS: Denies fever or body aches. Denies signs of ear pain such as pulling or digging inside ears. Denies recent or frequent ear infections. Denies itchy eyes, eye exudates, hx of conjunctivitis, erythema or flaking of eyelids. No changes in visual acuity noted. Denies epistaxis, nasal congestion, facial tenderness, positive for rhinorrhea. Denies headache, unusual behaviors, positive for lethargy. Denies chest pain, SOB, wheezing, adventitious breath sounds, chest congestion, or hx of congenital cardiac or pulmonary disease. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No c/of muscle pain, back ache or joint pain. Last BM yesterday, formed and brown. No change in bowel habits.
Constitutional: BP 107/72, HR 101, RR 22 unlabored. T 97.8 F°, Wt. 35.20 lbs, Ht. 37.6 in, BMI 17/90th percentile for age. Appropriately dressed for the season in clean clothes in good condition. Well nourished, good hygiene, appears well cared for by parents.
Neuro: Awake, interacts with family and NP student. Gait balance and coordination normal for age, DTR’s +2 bilaterally, muscle strength equal and symmetrical. Cranial nerves II-XII grossly intact. Speech 75% intelligible, counts to 10, knows 4 colors, hops on one foot, holds pencil and draws circle, triangle and cross. Mom reports that he will dress and undress himself and rides a tricycle easily Red reflex noted bilaterally,
PERRLA. Passed vision and hearing screening.
HEENT: No facial tenderness or masses. Bilateral periorbital edema. Sclera mildy injected, pale pink conjunctiva. TM’s pearly pink, intact, +cone of light, nares patent w/pale pink mucosa, small amount of clear discharge in nares, nasal septum midline, buccal mucosa pink and moist, tongue pink, no furrowing or lesions. Dental caries noted in lower molars. Incisors w/o discoloration or caries. Tonsils +2, pink, without erythema or exudates. Posterior pharynx moist pink.
CV: S1S2, RRR, no murmurs, rubs or gallops. +2 pulses in extremities. Cap. Refill <2secs. Skin warm and dry. RESP: Even, nonlabored respirations, BBS clear. GI: Soft, distended, liver edge palpable, fluid wave elicited. Nontender. No organomegaly. Genital: nl circumsized penis, urethral meatus WNL, no discharge noted, retractable testes, olive sized. MS: Neck supple w/ full ROM. Extremities: Bilateral +2 pitting edema of shins, ankles and feet. Labs: Urinalysis: pH 9.0, protein 500 mg/dL and moderate amount of blood. CMP: Na 133 Cl 108 Crea 0.3mg/dL and Total protein 4.9g/dL. Use the information in the above noted to answer the following: List the top three differential diagnoses (possible diagnoses) with rationale for each. For each diagnosis list the supportive objective and subjective data including the laboratory findings. What information in the laboratory/diagnostics report was key in determining the top differential diagnosis? Describe the basic pathophysiology of your top (number one) differential diagnosis. You can draw a flowchart if preferred. What are the potential complications that could occur if J.B. (the client) was not diagnosed and treated in a timely manner? J.B. was seen by three different health care providers before receiving a diagnosis. Why do you think this occurred? How could this problem have been prevented? What is treatment and management recommended for a client with J.B.’s top diagnosis? NUR 529 Scoring Guide: Case Study #2 for Nurse Practitioner Students Questions Points Possible Correct Responses Include These 1. List the top three differential diagnoses (possible diagnoses) with rationale for each. 15 (5 points per diagnosis and rationale) Correctly identify the number one diagnosis and provide valid rationale. Correctly identify two additional differential diagnosis, order of these may vary. The diagnoses should be plausible and supported in the rationale for each. 2. For the top diagnosis list the supportive objective and subjective data including the laboratory findings. 10 (5 points for objective data) (5 points for subjective data) Correctly identified 75% or more of the diagnostics/laboratory or other tests/assessments needed to confirm the diagnosis. 3. What information in the laboratory/diagnostics report was key in determining the top differential diagnosis? 10 Correctly identifies the key piece of data that most supports the top diagnosis. 4. Describe the basic pathophysiology of this syndrome. You can draw a flowchart if preferred. 15 Complete and accurate description of the basic pathophysiology of the problem identified in question 2. 5. What are the potential complications that could occur if J.B. (the client) was not diagnosed and treated in a timely manner? 10 Lists three of the most serious potential complications. 6. J. B. was seen by three different health care providers before receiving a diagnosis. Why do you think this occurred? How could this problem/issue have been prevented? 20 Describes common problems that occur in health care that prevent providers from determining an accurate diagnosis. Identifies importance of obtaining accurate history & physical assessment. 7. What is the treatment and management recommended for a client disorder described in question 2 above. 20 Accurate description of the treatment and management of a client diagnosed the disorder (top diagnosis) identified in question 2. Total 100