Assignment: Decision Tree for Neurological and Musculoskeletal Disorders NURS 6521

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Assignment: Decision Tree for Neurological and Musculoskeletal Disorders NURS 6521

A Sample Answer For the Assignment: Assignment: Decision Tree for Neurological and Musculoskeletal Disorders NURS 6521

Title: Assignment: Decision Tree for Neurological and Musculoskeletal Disorders NURS 6521

Introduction

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The most common trigger of dementia in senior individuals, which affects many people worldwide, is Alzheimer’s disease. It is classified as a neurodegenerative condition brought on by the harmful progression of age-dependent cognitive decline. There is accumulation of amyloid plaques made up of abnormal deposits of located in the extracellular brain parenchyma and hippocampus. In AD, neurofibril tangles can also form inside of the neuron. Alzheimer’s disease is characterized by a progressive memory loss and cognitive abnormalities.

The case study of Mr. Akkad, a 76-year-old Iranian man who was brought in by his son, will be covered in this essay. Following a clinical assessment and mini-mental state evaluation, the patient is identified as having a significant neurodegenerative illness caused by Alzheimer’s disease (DementiaCareCentral.com, 2020)

Decision 1 Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2weeks

Rivastigmine is a drug containing a cholinesterase inhibitor with the potential benefit of being pseudo-irreversible. The reversible binding and inactivation of cholinesterase by rivastigmine results in an increase in the level of acetylcholine at cholinergic synapses by blocking acetylcholine’s breakdown. The cholinesterase inhibitor rivastigmine is licensed for use in the treatment of mild to moderate dementia associated with Parkinson’s and Alzheimer’s diseases.

Alzheimer’s disease will develop more slowly as a result of the Exelon. The non-cognitive manifestations of Alzheimer’s disease may be treated with this medication. According to published reports, this medicine improves an Alzheimer’s patient’s cognitive functioning. In the instance of Mr. Akkad, this pharmacological therapy seeks to maximize and uphold the patient’s autonomy, functional capacity, and life quality (Rosenthal & Burchum, 2021).

In a certain period, the patient will start to show the potential effects of the medication. Exelon will slow the spread of the condition, but the patient won’t notice any effects right away. Therefore, doctors advised patients to report any potential changes in their health within three to six weeks, with or without improvement.

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Following the commencement of treatment, doctors should schedule meetings with the patient and family every three to six weeks to assess any changes in cognitive and behavioral issues and to gauge how the patient is responding to the medicine. Mr. Akkad’s patient visited the clinic again after 4 weeks, however there was no improvement in his conduct or cognitive abilities (Kazmierski et al., 2020)

Decision 2 Increase Exelon to 4.5 mg orally BID

The client has returned, and according to his son, neither his father’s cognitive nor behavioral functioning had improved. Additionally, the MMSE test results showed that the drugs’ recommended dosage was not likely to have any positive effects.  Mini-mental status examination is a helpful tool for gauging how well a patient is responding to treatment, and family input is crucial for determining the patient’s daily interests.

The second choice is to raise the dosage of rivastigmine in order to reduce symptoms. Exelon lessens the symptoms and slows the disease’s course, although it could take 6 to 8 weeks before memory and behavior start to improve (Kazmierski et al., 2020).

To achieve the best results, the clinical studies advise titrating the Exelon dose to the highest tolerable level. The patient came back with his son after four weeks. According to his son, he is tolerating the medication, attending religious services with family, and everyone is content. One issue is that his dad still finds humor in things that he once found to be serious (Kim et al., 2021).

Decision 3 Maintain current dose of Exelon

The third option is to keep the present dosage of medicine after assessing the condition of the patient by raising the amount in the second choice.  Since this patient is responding effectively to the dosage and because there are no negative side effects from this dosage. The patient’s symptoms are reportedly getting better gradually. Behavioral, cognitive, and daily living activity tests have shown that oral Exelon’s effectiveness is dose dependent (Kim et al., 2021).

The suggested course of treatment lessens symptoms while delaying the onset of the illness. It does not, however, completely reverse the disease. Healthcare professionals have a crucial role in educating patients about Alzheimer’s disease, including its signs, problems, treatment options, and positive and negative impacts. They can also help patients and their families find financial and legal resources.

Assignment Decision Tree for Neurological and Musculoskeletal Disorders NURS 6521
Assignment Decision Tree for Neurological and Musculoskeletal Disorders NURS 6521

However, it is vital to explain to the client and his kid that this illness is permanent and medications only help to lessen the clinical manifestations and help improve the patient’s cognitive and behavioral functionality. The patient did not report side effects of the medication during the re- visit. Additionally, you have the choice of increasing the dosage or supplementing it with an additional drug such as Namenda (Rosenthal & Burchum, 2021).

Conclusion

In conclusion, there is no therapy option that can offer a long-term solution for Alzheimer’s disease. The patient’s quality of life, ability to do everyday tasks, and cognitive and behavioral capabilities can all be enhanced by prescribed medications and suggested therapy.  It is a neurogenerative condition that develops slowly and places a heavy strain on sufferers and family.

In order to reduce the negative impacts of this condition on patients and their families, it is crucial to create appropriate and effective decisions. Making sure patients with it have enough sleep and rest in between stimulating activities and providing a tranquil environment for these individuals are crucial (DementiaCareCentral.com, 2020).

References

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.

Kim, B., Noh, G. O., & Kim, K. (2021). Behavioral and psychological symptoms of dementia in patients with Alzheimer’s disease and family caregiver burden: a path analysis. BMC      Geriatrics, 21(1), 160.https://doi-org.ezp.waldenulibrary.org/10.1186/s12877-021-02109       w

DementiaCareCentral.com. (2020, October 7). Mini-mental state exam (MMSE) alzheimer’s        /dementia test: Administration, accuracy and scoring. Dementia             CareCentral.https://www.dementiacarecentral.com/mini-mental-state-exam/.

Kazmierski, J., Messini-Zachou, C., Gkioka, M., & Tsolaki, M. (2018). The impact of a long-      term rivastigmine and donepezil treatment on all-cause mortality in patients with           Alzheimer’s disease. American Journal of Alzheimer’s Disease & OtherDementias®,33(6), 385-393

The case study depicts a 43-year-old white male who presents with a complaint of pain. He uses a set of clutches when ambulating. The patient reports that he has been referred for psychiatric assessment by his family doctor since the doctor perceived that he had psychological pain (Laureate Education, 2016). The pain began seven years ago after sustaining a fall and landed on the right hip. Four years ago, it was revealed that the cartilage around the right hip joint had a 75% tear. 

However, no surgeon was willing to perform a total hip replacement since they believed that there would be tissue repair over time (Laureate Education, 2016). He reports having severe cramping of the right extremity. A neurologist diagnosed  him with complex regional pain syndrome (CRPS). He states that he gets low moods at times but denies being depressed.  He had been prescribed with Hydrocone but used it in low doses due to drowsiness and constipation, and the drug does not manage pain effectively (Laureate Education, 2016). The mental status exam is unremarkable.

Decision Point One: Savella 12.5 mg orally once daily on Day 1, followed by 12.5 mg BD on Day 2 and 3, then 25 mg BD on days 4-7 and then 50 mg BD after that.

Reason: Savella is a serotonin-norepinephrine reuptake inhibitor that has NMDA antagonist activity, which brings analgesia at the nerve endings (Cording et al., 2015). It is indicated for fibromyalgia and thus effective for this client (Cording et al., 2015). I prescribed Savella to help in pain management and improve the overall mood.

Expected Result: I anticipated that Savella would lower the degree of pain. However, it was expected that the client would experience adverse effects such as nausea, constipation, headache, hot flushes, and insomnia.

Expected Vs. Actual Results: The client returned to the clinic after for weeks without using crutches but with a bit of limping. He states that the pain has been more manageable. The pain is severe in the morning but improves throughout the day (Laureate Education, 2016). On a scale of 1-10, the client rates the pain at four and states that he gets to a point on most days where he does not need crutches.

Nevertheless, he reported having increased sweating, sleeping difficulties, nausea, and palpitations (Laureate Education, 2016). His BP was 147/92, and the pulse at 110. He denied having suicidal ideations and was still future-oriented.

Decision Point 2: Continue with Savella but lower dose to 25 mg twice a day.

Reason: I selected this decision to lower the severity of the adverse effects of Savella, which include nausea, constipation, headache, hot flushes, and insomnia (Cording et al., 2015).

Expected Result: Reduction in the dose of Savella would help control the side effects but lower the degree of pain control.

Expected Vs. Actual Results: The client returned to the clinic in four weeks using crutches and rates his current pain at 7/10. He reports that his condition has declined since the previous month (Laureate Education, 2016). He states that he sleeps at night but frequently wakes up due to pain in the right leg and foot. The BP is at 124/87 and pulse at 87. He denies having palpitations and suicidal ideations but is discouraged by the slip in pain management and seems sad.

Decision Point 3: Change Savella to 25 mg in the morning and 50 mg at Bedtime.

I reduced the dosage in the morning since the pain is mostly under control and increased the dose at Bedtime when there is less control (Resmini et al., 2015).

Expected Result: By lowering the morning dose and increasing the bedtime dose, I expected that the client’s pain symptom would improve while at the same time controlling the side effects of Savella (Resmini et al., 2015).

Expected Vs. Actual Results: The client reported an improvement in the pain with a rate of 3/10 denied having any side effects from the drug.

References

Cording, M., Derry, S., Phillips, T., Moore, R. A., & Wiffen, P. J. (2015). Milnacipran for pain in fibromyalgia in adults. Cochrane Database of Systematic Reviews, (10).

Laureate Education. (2016). Case Study: A Caucasian man with hip pain. Baltimore, MD: Author.

Resmini, G., Ratti, C., Canton, G., Murena, L., Moretti, A., & Iolascon, G. (2015). Treatment of complex regional pain syndrome. Clinical cases in mineral and bone metabolism: the official journal of the Italian Society of Osteoporosis, Mineral Metabolism, and Skeletal Diseases12(Suppl 1), 26–30. https://doi.org/10.11138/ccmbm/2015.12.3s.026

INSTRUCTIONS

For your Assignment, your Instructor will assign you one of the decision tree interactive media pieces provided in the Resources. As you examine the patient case studies in this module’s Resources, consider how you might assess and treat patients presenting symptoms of neurological and musculoskeletal disorders.

 

Photo Credit: KATERYNA KON/SCIENCE PHOTO LIBRARY / Science Photo Library / Getty Images

To Prepare

  • Review the interactive media piece assigned by your Instructor.
  • Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.
  • Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned.
  • You will be asked to make three decisions concerning the diagnosis and treatment for this patient. Reflect on potential co-morbid physical as well as patient factors that might impact the patient’s diagnosis and treatment.

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By Day 7 of Week 8

Write a 1- to 2-page summary paper that addresses the following:

Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.

Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.

What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.

Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.

Assignment: Decision Tree for Neurological and Musculoskeletal Disorders

The case study is about a 76-year-old Iranian male accompanied to the office by his son after exhibiting odd behavior. The patient scored 18 out of 30 in the Mini-Mental State Exam. He is diagnosed with Major neurocognitive disorder secondary to Alzheimer’s disease. This paper provides a summary of the treatment decisions taken, what I was hoping to achieve, and compare the difference between the expected and actual results.

Decision One

In the first decision, I initiated the patient on Rivastigmine 1.5 mg PO BID with an increase to 3 mg orally BID in two weeks. The decision is supported by evidence-based literature since Rivastigmine is an irreversible inhibitor of acetylcholinesterase and its therapeutic effect includes improving cholinergic function. It improves cognitive symptoms by modifying acetylcholine transmitters (Khoury et al., 2018). Rivastigmine is indicated in treating mild to moderate AD dementia, as in the case of this patient. I hoped that initiating Rivastigmine would delay cognitive decline in the patient and enhance his performance of ADLs. I also hoped that Rivastigmine would improve the patient’s social behavior. The expected and actual outcomes were different since the patient still displayed odd social behaviors after four weeks of treatment. The MMSE score remained at 18, and the patient had deficits in registration, orientation, attention, recall, and calculation.

Decision Two

In decision two, I increased Rivastigmine to 4.5 mg orally BD. The dose was increased since the initial dose did not have a positive impact.  Khoury et al. (2018) explain that Rivastigmine should be gradually increased to allow the clinician to monitor adverse effects. The study further explains that Rivastigmine can take months to show improvement in neurocognitive symptoms, thus increasing the dose is important to show improvement over time. Therefore, the decision is based on evidence-based literature. I hoped that increasing the dose might result in a positive outcome in alleviating the patient’s cognitive and behavioral symptoms. The actual and expected outcomes were similar to some degree since the son reported that the father had started attending religious services with the family. However, the son reported that the father had not improved and was amused by serious things.

Decision Three

In decision three, I increased Rivastigmine to 6 mg orally BD to improve the patient’s cognitive symptoms. Besides, the patient did not report any side effects with the drug, and thus increasing the dose was appropriate. Folch et al. (2018) assert that Rivastigmine should be increased to the maximum dose before changing or augmenting the treatment. I hoped that increasing the dose would improve the client’s social behavior to a greater degree, and the son would report an improvement in the father’s condition. Besides, I hoped that increasing the dose would improve the patient’s cognitive symptoms and the MMSE score. The expected and actual results were similar to some extent since the patient exhibited improved social interactions and engaged in family activities. Besides, the odd behaviors had decreased as the patient rarely got amused by serious things.

Conclusion

The patient was initiated with Rivastigmine 1.5 mg BD to improve the cognitive and behavioral symptoms. However, the initial dose did not achieve the desired effect, which resulted in increasing the dose to 4.5 BD. Increasing the dose led to some improvement in social interactions, but no cognitive improvement was noted. Rivastigmine was then increased to 6 mg BD to improve the cognitive and behavioral symptoms.

 

 

References

Folch, J., Busquets, O., Ettcheto, M., Sánchez-López, E., Castro-Torres, R. D., Verdaguer, E., Garcia, M. L., Olloquequi, J., Casadesús, G., Beas-Zarate, C., Pelegri, C., Vilaplana, J., Auladell, C., & Camins, A. (2018). Memantine for the Treatment of Dementia: A Review on its Current and Future Applications. Journal of Alzheimer’s disease: JAD62(3), 1223–1240. https://doi.org/10.3233/JAD-170672

Khoury, R., Rajamanickam, J., & Grossberg, G. T. (2018). An update on the safety of current therapies for Alzheimer’s disease: focus on rivastigmine. Therapeutic advances in drug safety9(3), 171–178. https://doi.org/10.1177/2042098617750555

You will submit this Assignment in Week 8.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

Please save your Assignment using the naming convention “WK8Assgn+last name+first initial.(extension)” as the name.

Click the Week 8 Assignment Rubric to review the Grading Criteria for the Assignment.

Click the Week 8 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.

Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK8Assgn+last name+first initial.(extension)” and click Open.

If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.

Click on the Submit button to complete your submission.

Grading Criteria

To access your rubric:

Week 8 Assignment Rubric

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:

Submit your Week 8 Assignment draft and review the originality report.

Submit Your Assignment by Day 7 of Week 8

To participate in this Assignment:

Week 8 Assignment

 

 

What’s Coming Up in Week 7?

 

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images

Next week, you will continue working on your Assignment started in Week 6, and you will complete your Midterm Exam.

Next Week

Week 6: Neurologic and Musculoskeletal Disorders

Sabrina is a 26 year old female who has just been diagnosed with multiple sclerosis. She has scheduled an appointment for a follow up with her physician but has several questions about her diagnosis and is calling the Nurse Helpline for her hospital network. As she talks with the advanced practice nurse, she learns that her diagnosis also impacts her neurologic and musculoskeletal systems. Although multiple sclerosis is an autoimmune disorder, both the neurologic and musculoskeletal systems will be affected by adverse symptoms that Sabrina needs to be aware of and for which specific drug therapy plans and other treatment options need to be decided on.

As an advanced practice nurse, what types of drugs will best address potential neurologic and musculoskeletal symptoms Sabrina might experience?

This week, you will evaluate patients for the treatment of neurologic and musculoskeletal disorders by focusing on specific patient case studies through a decision tree exercise. You will analyze the decisions you will make in the decision tree exercise and reflect on your experiences in proposing the recommended actions to address the health needs in the patient case study. Assignment: Decision Tree for Neurological and Musculoskeletal Disorders NURS 6521

Learning Objectives

Students will:

  • Evaluate patients for treatment of neurologic and musculoskeletal disorders
  • Analyze decisions made throughout the diagnosis and treatment of patients with neurologic and musculoskeletal disorders
  • Justify decisions made throughout the diagnosis and treatment of patients with neurologic and musculoskeletal disorders

 

 

Learning Resources

Required Readings (click to expand/reduce)

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.

  • Chapter 11, “Basic Principles of Neuropharmacology” (pp. 67–71)
  • Chapter 12, “Physiology of the Peripheral Nervous System” (pp. 72–81)
  • Chapter 12, “Muscarinic Agonists and Cholinesterase Inhibitors” (pp. 82–89)
  • Chapter 14, “Muscarinic Antagonists” (pp. 90-98)
  • Chapter 15, “Adrenergic Agonists” (pp. 99–107)
  • Chapter 16, “Adrenergic Antagonists” (pp. 108–119)
  • Chapter 17, “Indirect-Acting Antiadrenergic Agents” (pp. 120–124)
  • Chapter 18, “Introduction to Central Nervous System Pharmacology” (pp. 125–126)
  • Chapter 19, “Drugs for Parkinson Disease” (pp. 127–142)
  • Chapter 20, “Drugs for Alzheimer Disease” (pp. 159–166)
  • Chapter 21, “Drugs for Seizure Disorders” (pp. 150–170)
  • Chapter 22, “Drugs for Muscle Spasm and Spasticity” (pp. 171–178)
  • Chapter 59, “Drug Therapy of Rheumatoid Arthritis” (pp. 513–527)
  • Chapter 60, “Drug Therapy of Gout” (pp. 528–536)
  • Chapter 61, “Drugs Affecting Calcium Levels and Bone Mineralization” (pp. 537–556)
Required Media (click to expand/reduce)

Laureate Education (Producer). (2019b). Alzheimer’s disease [Interactive media file]. Baltimore, MD: Author.

In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat Alzheimer’s disease.

Laureate Education (Producer). (2019e). Complex regional pain disorder [Interactive media file]. Baltimore, MD: Author.

In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat complex regional pain disorders.

Disorders of The Nervous System

Reflect on the comprehensive review of disorders of the nervous system and think about how you might recommend or prescribe pharmacotherapeutics to treat these disorders. (15m)

Disorders of the Nervous System©2019 Laureate Education, Inc.1Disorders of the Nervous SystemProgram Transcript[MUSIC PLAYING] NORBERT MYSLINSKI: In the year 2000, Alvin Toffler, who was the author of Future Shock back in the 1960s, was asked this question. What do you think is the most important question facing mankind in the new millennium? He answered by saying, “What does it mean to be human?” FEMALE SPEAKER: This week, Dr. Norbert Myslinski takes an in-depth look at the human brain and how it is affected by disorders of the nervous system. NORBERT MYSLINSKI: The most human part of the body is the brain. This is the human brain. It doesn’t look like very much. It’s only about three pounds, and it’s kind of wrinkled. But if you think about it, this is the product of 3 and 1/2 billion years of evolution. It is probably the most complicated machine, or organ, or article that we know of in the universe, and it is composed of a hundred billion neurons, a hundred billion neurons. And if you look at the supporting cells, the glia, there’s about a trillion. And if you look at one of the most important parts, the connections between all of these cells, the connections that are responsible for memory and for all of our activities, there’s about a quadrillion, a quadrillion with this individual brain. And I’m sure that through the centuries, through the millions of years of our existence on this planet, this brain has evolved, and this brain has had pathologies of different kinds, and changes of many kinds. Initially, we only had this part of the brain. The dinosaurs, for instance, had this basic brain. And this is the basic brain that controls our breathing, controls our respiration, controls our heart rate, controls of all the other autonomic or vegetative functions of the body. And so sometimes, we call this part of the brain the reptilian brain. It’s the vegetative part. And then as the brain evolved through the centuries, through the millennia, another big step in the evolution was the development of this part of the brain. That’s the limbic system. And the limbic system is responsible for emotion, the wagging of the tail of a dog, the purring of a cat. This big step occurred mainly with the mammals, and so we call this the mammalian brain or the emotional brain. And the next big step in the evolution of the brain was the cerebral cortex, this part. This is the flower of the human brain. That big step occurred with the

 

Disorders of the Nervous System©2019 Laureate Education, Inc.2development of the homo sapiens, and it involves cognition, and so we call this the human brain. And so we have this triune brain. It’s a brain that’s developed over the years through time in that order. But we see this development in that order everyday. We see it inside every woman who is pregnant, because every fetus who’s developing a brain develops it exactly the same way. We first have the vegetative reptilian brain. And then months later, we have the development of the limbic part of the brain. And then we have the development of the human or cognitive part of the brain. And the cognitive part of the brain continues developing after birth. It continues developing through childhood, through adulthood. And hopefully, it’ll continue until the day we die. So we have this development not only through the years, but also in utero. It’s very interesting that one of the major diseases that we have of the elderly is Alzheimer’s disease. Alzheimer’s disease is very dehumanizing because it attacks that part of the brain that is one of our main humanistic parts, and that is our memory. It attacks who we are, and it’s a progressive degenerative disease. And what’s interesting is that it destroys the brain in the reverse order of its development. And what happens first, there is a group of cells down here, nucleus of Meynert. And they have a neurotransmitter called acetylcholine. And it preferentially, this group of cells preferentially degenerates, and it has pathways to all different parts of the brain. But one of the parts is over here, the hippocampus, which has to do with memory, long-term memory. And so this is what happens first. And as it progresses, there are all these plaques and tangles, we call them, that develop and choke different cells of the brain. And it continues to increase through all parts of the brain until you get many different cognitive deficits. And after that, then it attacks the mammalian brain, the emotional part of the brain. After that, it attacks the reptilian brain, the vegetative brain, and then you lose your vital functions, and then you die about 10 to 12 years, usually, after first diagnosis. So you have this reversal. Now, it’s very interesting because a lot of people are afraid of losing their memory, of getting Alzheimer’s disease. And rightfully so, because as our population ages and more and more people are older, more and more people are going to get Alzheimer’s disease. There’s about 4 million in the United States right now. And if you are lucky enough to live to the age of 85, half— half of the people will have Alzheimer’s disease. So it’s going to be pretty prevalent, and it’s going to

 

Disorders of the Nervous System©2019 Laureate Education, Inc.3increase in leaps and bounds as we get older, and it’s going to be a more and more important disease for the nursing profession and the health professionals. 65% of the dementias are of the Alzheimer’s type, but there are others that are not. And it’s important to be diagnosed, and to be examined, and tested, because if it’s a dementia not of Alzheimer’s, then it may be cured, even though Alzheimer’s itself is not curable, nowadays. Now, there’s another idea that I mentioned earlier, and that is that the human brain keeps on developing after we’re born until the day we die. And one of the reasons for that is because of the plasticity of the brain. That means the malleability. That means the changeability of the brain. The brain can adapt to challenges put to it, to experiences, to our needs, and our wants. It can keep changing. All of these connections, these quadrillion connections among the different parts of the brain do change, increase and decrease. As a matter of fact, the more we challenge the brain, the more we learn, the more we experience, the more connections you have, all right? If you take two animals and put one in insipid sort of adult environment and one in a rich environment and examine their brains at the end of their lives, the one in the rich environment has many more connections, many more synapses between the different— and that is the basis of memory. That is the basis of intelligence, not the number of your cells, not inside of your brain. It’s the number of synapses that we have, the number of engrams that we have withing the brain. So we have this plasticity, this growth developing. So your brain is continuously changing. Hopefully, the brain that you had before I started talking is not going to be the same brain as when I finish talking, OK? So it’s important not to traumatize the brain, and to protect it. And we’ve been giving many different protections for the brain. Unlike other organs and parts of the body, the brain has a skull to protect it. The brain has cerebral spinal fluid in it to protect it. The brain has a barrier between it and the blood that no other organ has. It’s called the blood-brain barrier to keep the toxins and bad materials of blood from getting into the brain. Before the golden age of pharmacology in the late ’50s, and they did everything they can, and they did a lot of experimentation with the brain. For instance, they were doing the frontal lobotomies that they thought would help individuals decrease agitation, as we know how terrible that was now. So they tried this stimulation of this pathway for people that are pathologically depressed, and there would be wires from there all the way down to a little box on their belt, and they’d press a button, and they feel good. And if you ask how

 

Disorders of the Nervous System©2019 Laureate Education, Inc.4they felt, they’d say, oh, I feel contentment, and joy, and so forth, and they feel good. But it didn’t last very long because that would destroy the pathway, and it would become refractory, and it wouldn’t work. And also, right after that, the pharmacology started, and the antipsychotic drugs came in, and so that was a lot less invasive, and a lot more effective. This dichotomy between the right and left sides of the brain is very important in understanding our perception of the world. I mentioned earlier that there are a quadrillion synapses within the brain, and this is the essential unit of memory, and it’s the essential unit of functioning of the brain. And when there is a disorder of the brain, more often than not, it has to do with the synapse. The synapse is that point of communication between two different neurons. And when you have this dysfunction or when the neuron itself dies, you have a decrease in a neurotransmitter. A neurotransmitter is a chemical that is essential for the communication. And so a lot of diseases are characterized and identified by the fact that they don’t have a certain neurotransmitter. There are many different types of neurotransmitters throughout the brain. An ideal way to study pathopharmacology is to look at a disease like Parkinson’s disease. Now, Parkinson’s disease was first analyzed back in the 1950s, when they looked at the brains of dead patients, and they did autopsies, and found that a small part of the basal ganglia called the nigostriatal pathway preferentially degenerates in these patients. And then the biochemists came along, and they analyzed the pathway, and they found that dopamine was the vital chemical, the neurotransmitter, within that pathway. And then the pharmacologists came along, and they said, you know what? I wonder if we can replace that dopamine, if we can alleviate some of the symptoms. And so they tried it. They gave dopamine. It didn’t work because it couldn’t cross the blood-brain barrier. But eventually, they gave a precursor that did cross the blood-brain barrier. And eventually, it did work, and it was called L-DOPA, and it was one of the big breakthroughs. And so patients with Parkinson’s disease then found out that their symptoms can be alleviated by taking this drug. And that’s because we replaced the neurotransmitter that is being depleted with an exogenous neurotransmitter of a similar type, and it alleviated the symptoms. If we look at Alzheimer’s disease, they thought that they could do the same thing. They looked at the Parkinson’s story, and they said, hey, if they can do it, we can

 

Disorders of the Nervous System©2019 Laureate Education, Inc.5do it with Alzheimer’s. Because in Alzheimer’s, we also have a small pathway that degenerates, but that has acetylcholine as its neurotransmitter. So they tried to give a drug to exacerbate the acetylcholine in the brain, and it did not work. Then they tried some other drugs, but it seemed to work, but they had a big side effect of liver toxicity. And so they put that drug aside. And so they kept studying, and studying, and studying. So by 10, 20, 30 years later, they bring that drug out again which had the big liver toxicity. They were able to find a way to minimize the liver toxicity, and they found that it does work in some Alzheimer’s patients. and that this drug is Aricept. It was the first drugs used to treat Alzheimer’s disease. So that’s one way in which pharmacology can be used to alleviate the symptoms of neurodegenerative disorders. You have similar ideas with Huntington’s chora, Huntington’s disease. You have a similar situation with epilepsy in the sense that you’re not really replacing something, but you’re exacerbating the pathway that can actively inhibit these epileptic foci that I talked about before from spontaneously discharging, and causing that epileptic seizure. So you can give drugs to exacerbate certain pathways, stimulate certain pathways, just like drugs [INAUDIBLE] stimulate the positive reinforcement area, and make us feel good. Now, you can have drugs that can stimulate other pathways in the brain pharmacologically so that you can alleviate symptoms, inhibit certain things, stimulate certain things, and so forth. Now, besides chemically doing it, some of the more recent therapies are going back 50 years, and they’re trying to electrically stimulate certain parts of the brain. Yeah, you have certain therapies now based on new technological developments where you have, for instance, deep brain stimulation, where they actually take an electrode, and stimulate, and implant it in the brain semi-permanently so that if you stimulate it, then you can alleviate the movements of somebody with Parkinson’s disease, and they can control their movements, and they have an actual electrode in there being stimulated in a certain part of the brain. So you can do it physically as well as chemically. Sometimes, you surgically can remove a certain part of the brain to alleviate symptoms, like in Parkinson’s disease. So there’s a lot of avenues of approach that we can use to treat the brain, whether surgically or pharmacologically.

The case study concerns a 43-year-old man with a history of chronic pain for several years after sustaining a fall and now ambulates with crutches. He has been referred for a psychiatric evaluation by his family physician after suspecting his pain is psychological, and he has been exaggerating the pain to get a narcotic prescription to get high.

He complains of cooling and intense cramping in the right leg. He has been diagnosed with complex regional pain syndrome (CRPS). The purpose of this paper is to explain the interventions for each decision and if they are backed by evidence-based literature.

Decisions Recommended For the Patient Case Study

The first decision was to start Amitriptyline 25 mg PO QHS and increase it by 25 mg every week to a maximum of 200 mg daily. The decision is supported by the study by Shim et al. (2019), which found that Amitriptyline is an effective evidence-based treatment for neuropathic pain disorder and peripheral diabetic neuropathic pain. In decision two, I maintained Amitriptyline and increased the dose to 125 mg with a maximum target of 200 mg.

The patient was to take the medication an hour earlier than usual. Increasing the dose is supported by the article by Eldufani et al. (2020), which recommends slow titration of the Amitriptyline dose if a patient exhibits a positive response to the initial dose. It also recommends taking the bedtime dose an hour earlier to minimize morning sleepiness.

In decision three, I continued Amitriptyline at 125 mg and referred the patient to a life coach for counseling on nutrition and exercise. Weight gain is a documented side effect of Amitriptyline. Brueckle (2020) backs this intervention by asserting that patients on medications associated with weight gain should be counseled on lifestyle modification in diet and exercise for a healthy weight.

What I Was Hoping To Achieve With the Decisions I Recommended For the Patient Case Study

By initiating the patient on Amitriptyline, I hoped it would help improve the client’s mood swings, alleviate pain to 4/10, and ambulate without crutches within four weeks. Komoly (2019) established that Amitriptyline helps alleviate pain and autonomic and motor symptoms in CRPS cases. I hoped that increasing Amitriptyline to 125 mg would alleviate the limb to 3/10, and taking the drug an hour earlier would prevent morning sleepiness.

Taking the medication an hour earlier decreases morning sleepiness (Rosenthal & Burchum, 2021). In decision three, I hoped that referring the client for lifestyle modification counseling would guide him in practicing a healthy lifestyle in dietary and physical exercise habits that would prevent unhealthy weight gain. Aguilar-Latorre et al. (2022) recommend counseling on lifestyle modification to enable patients on TCAs to manage their weight and avoid being overweight/obese.

Difference between What You Expected To Achieve With Each of the Decisions and the Results of the Decision in the Exercise

In the first decision, the pain decreased to a 6/10, and the patient ambulated without crutches. The pain severity was not as anticipated, probably because of the low Amitriptyline dose and duration it takes to have maximum effect. In the second decision, the patient’s pain was reduced to 4/10, comparable to the expected outcome of a pain severity of 3/10.

Conclusion

The PMHNP started the patient on an initial dose of Amitriptyline of 25 mg QHS, which was to be increased by 25 mg weekly to 200 mg. The drug led to a positive response and was increased to 125 mg QHS to improve the patient’s pain. The medication led to weight gain, and the PMHNP referred the client to a life coach for counseling on a healthy lifestyle.

References

Aguilar-Latorre, A., Pérez Algorta, G., Navarro-Guzmán, C., Serrano-Ripoll, M. J., & Oliván-Blázquez, B. (2022). Effectiveness of a lifestyle modification programme in the treatment of depression symptoms in primary care. Frontiers in medicine9, 954644. https://doi.org/10.3389/fmed.2022.954644

Brueckle, M. S., Thomas, E. T., Seide, S. E., Pilz, M., Gonzalez-Gonzalez, A. I., Nguyen, T. S., … & Muth, C. (2020). Adverse drug reactions associated with Amitriptyline—protocol for a systematic multiple-indication review and meta-analysis. Systematic reviews9(1), 1-8. https://doi.org/10.1186/s13643-020-01296-8

Eldufani, J., Elahmer, N., & Blaise, G. (2020). A medical mystery of complex regional pain syndrome. Heliyon6(2), e03329. https://doi.org/10.1016/j.heliyon.2020.e03329

Komoly, S. (2019). Treatment of complex regional pain syndrome with Amitriptyline. Ideggyogyaszati szemle72(7-8), 279-281. https://doi.org/10.18071/isz.72.0279

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.

Shim, H., Rose, J., Halle, S., & Shekane, P. (2019). Complex regional pain syndrome: a narrative review for the practicing clinician. British Journal of Anaesthesia123(2), e424–e433. https://doi.org/10.1016/j.bja.2019.03.030

I absolutely loved your response, and I found it not only incredibly informative, but succinct as well. In short, I greatly appreciate the plethora of tests you recommended for the sake of maximizing the certainty under which one might offer the patient a diagnosis. As you mentioned, not only does this “help guide the differential diagnoses with physical exam findings”; however, it also “saves the patient money”.

Another thing I appreciated was your focus on trying to find a possible connection between the two ankles and their respective pains (this, I saw as evidenced chiefly through your proposed physical examination assessing and comparing the movement, tenderness, range of motion, pain, etc. of the patient’s ankles). You ask many questions at the beginning of your response, and I also want to voice how much I appreciate that as well.

It is important to delve deeply and patiently into treating a patient, and if not much information is given (as was the case here), this habit of intense inquiry will serve you – and your patients – very well. Las, I would like to note how you wrote that each ankle injury assessment can be conducted fluently and swiftly, as this is also important in healthcare. Oftentimes, practitioners and patients don’t have copious amounts of time to spend on an issue, and timeliness is important. For these reasons, once again, I absolutely loved this response!

Ball, J., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). Elsevier.

Larkins, L. W., Baker, R. T., & Baker, J. G. (2020). Physical examination of the ankle: A review of the original orthopedic special test description and scientific validity of common tests for ankle examination. Archives of rehabilitation research and clinical translation, 2(3), 100072. https://doi.org/10.1016/j.arrct.2020.100072Links to an external site.

The case study depicts a 43-year-old white male who presents with a complaint of pain. He uses a set of clutches when ambulating. The patient reports that he has been referred for psychiatric assessment by his family doctor since the doctor perceived that he had psychological pain (Laureate Education, 2016). The pain began seven years ago after sustaining a fall and landed on the right hip. Four years ago, it was revealed that the cartilage around the right hip joint had a 75% tear. 

However, no surgeon was willing to perform a total hip replacement since they believed that there would be tissue repair over time (Laureate Education, 2016). He reports having severe cramping of the right extremity. A neurologist diagnosed him with complex regional pain syndrome (CRPS). He states that he gets low moods at times but denies being depressed.  He had been prescribed with Hydrocone but used it in low doses due to drowsiness and constipation, and the drug does not manage pain effectively (Laureate Education, 2016). The mental status exam is unremarkable.  

Decision Point One: Savella 12.5 mg orally once daily on Day 1, followed by 12.5 mg BD on Day 2 and 3, then 25 mg BD on days 4-7 and then 50 mg BD after that.

Reason: Savella is a serotonin-norepinephrine reuptake inhibitor that has NMDA antagonist activity, which brings analgesia at the nerve endings (Cording et al., 2015). It is indicated for fibromyalgia and thus effective for this client (Cording et al., 2015). I prescribed Savella to help in pain management and improve the overall mood.

Expected Result: I anticipated that Savella would lower the degree of pain. However, it was expected that the client would experience adverse effects such as nausea, constipation, headache, hot flushes, and insomnia.

Expected Vs. Actual Results: The client returned to the clinic after for weeks without using crutches but with a bit of limping. He states that the pain has been more manageable. The pain is severe in the morning but improves throughout the day (Laureate Education, 2016). On a scale of 1-10, the client rates the pain at four and states that he gets to a point on most days where he does not need crutches. Nevertheless, he reported having increased sweating, sleeping difficulties, nausea, and palpitations (Laureate Education, 2016). His BP was 147/92, and the pulse at 110. He denied having suicidal ideations and was still future-oriented.

Decision Point 2: Continue with Savella but lower dose to 25 mg twice a day.

Reason: I selected this decision to lower the severity of the adverse effects of Savella, which include nausea, constipation, headache, hot flushes, and insomnia (Cording et al., 2015).

Expected Result: Reduction in the dose of Savella would help control the side effects but lower the degree of pain control.

Expected Vs. Actual Results: The client returned to the clinic in four weeks using crutches and rates his current pain at 7/10. He reports that his condition has declined since the previous month (Laureate Education, 2016). He states that he sleeps at night but frequently wakes up due to pain in the right leg and foot. The BP is at 124/87 and pulse at 87. He denies having palpitations and suicidal ideations but is discouraged by the slip in pain management and seems sad.

Decision Point 3: Change Savella to 25 mg in the morning and 50 mg at Bedtime.

I reduced the dosage in the morning since the pain is mostly under control and increased the dose at Bedtime when there is less control (Resmini et al., 2015).

Expected Result: By lowering the morning dose and increasing the bedtime dose, I expected that the client’s pain symptom would improve while at the same time controlling the side effects of Savella (Resmini et al., 2015).

Expected Vs. Actual Results: The client reported an improvement in the pain with a rate of 3/10 denied having any side effects from the drug.  

References

Cording, M., Derry, S., Phillips, T., Moore, R. A., & Wiffen, P. J. (2015). Milnacipran for pain in fibromyalgia in adults. Cochrane Database of Systematic Reviews, (10).

Laureate Education. (2016). Case Study: A Caucasian man with hip pain. Baltimore, MD: Author.

Resmini, G., Ratti, C., Canton, G., Murena, L., Moretti, A., & Iolascon, G. (2015). Treatment of complex regional pain syndrome. Clinical cases in mineral and bone metabolism: the official journal of the Italian Society of Osteoporosis, Mineral Metabolism, and Skeletal Diseases12(Suppl 1), 26–30. https://doi.org/10.11138/ccmbm/2015.12.3s.026

Decision Tree for Neurological and Musculoskeletal

Resources

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WEEKLY RESOURCES

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Submit your Assignment, started in Week 6.

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submission information

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Subjective Data Collection: 50 of 50 (100.0%)

Hover To Reveal…

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

    • Found: Indicates an item that you found.

    • Available: Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Current Health Status

    • Finding: Confirmed reason for visit

    • Finding: Reports needing a pre-employment physical (Found) Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. Example Question: Can I confirm that you are here for a physical?

    • Finding: Reports no current acute health problems (Found) Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. Example Question: Do you have any current health problems?

    • Finding: Asked about last visit to a healthcare provider

    • Finding: Last visit to a healthcare provider was 4 months ago (Found) Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Example Question: When did you see a healthcare provider?

    • Finding: Reason for last visit was annual gynecological exam (Found) Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. Example Question: Why did you see a healthcare provider?

    • Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler (Found) Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Example Question: When was your last physical exam?

    • Finding: Asked about current prescription medications

    • Finding: Reports taking diabetes medication (Found) Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it. Example Question: Have you been taking medication for your diabetes?

    • Finding: Reports using a daily inhaler (Found) Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. Example Question: Do you use a daily inhaler?

    • Finding: Reports taking prescription birth control pills (Found) Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Example Question: Are you taking any form of birth control?

    • Finding: Followed up about diabetes medication

    • Finding: Medication is metformin (Found) Pro Tip: Follow up questions about Tina’s medication history will help you to understand her treatment plan and recent health history. Example Question: What is the name of your diabetes medication?

    • Finding: Started taking metformin 5 months ago (Available) Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history. Example Question: How long have you been taking metformin?

    • Finding: Reports that eating probiotic yogurt helps with side effects and they have abated over time (Available) Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history. Example Question: Have you noticed any side effects from the metformin?

    • Finding: Followed up on metformin frequency and dose

    • Finding: Reports taking metformin twice daily (Found) Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history. Example Question: How many times a day do you take metformin?

    • Finding: Metformin dose is 850 mg (Found) Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history. Example Question: What is the dose of your metformin?

    • Finding: Asked about asthma medication

    • Finding: Reports using Flovent inhaler twice daily (Found) Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation. Example Question: How often do you use your daily inhaler?

    • Finding: Has a Proventil rescue inhaler (Available) Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it. Example Question: Do you have a rescue inhaler?

    • Finding: Last use of Proventil inhaler was three months ago (Available) Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. Example Question: When did you last use your rescue inhaler?

    • Finding: Has used Proventil inhaler twice in the last year (Available) Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation. Example Question: How often do you use your rescue inhaler?

    • Finding: Followed up about birth control prescription

    • Finding: Started taking birth control 4 months ago (Available) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Example Question: How long ago did you start taking birth control?

    • Finding: Reason for birth control was to manage PCOS symptoms (Found) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. Example Question: Why did you decide to start taking birth control?

    • Finding: Birth control type is Yaz (drospirenone and ethinyl estradiol) (Found) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Confirming the name of Tina’s birth control pill will solicit information about her health history and current treatment plan. Example Question: What type of birth control do you use?

    • Finding: Takes birth control pill daily (Found) Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan. Example Question: How often do you take your birth control pill?

    • Finding: Takes birth control pill at the same time every day (Found) Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan. Example Question: Do you take your pill at the same time every day?

    • Finding: Reports no skipped days (Available) Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan. Example Question: Have you missed any days of your birth control pill?

    • Finding: Asked about current non-prescription medications

    • Finding: Reports rare Advil use for cramps (Found) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes non prescription drugs will indicate her current treatment plan. Example Question: Do you take Advil?

    • Finding: Reports no OTC herbal products (Available) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes herbal products will indicate her current treatment plan. Example Question: Do you use any herbal products?

    • Finding: Reports no OTC vitamins (Available) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes vitamins will indicate her current treatment plan. Example Question: Do you take any vitamins?

    • Finding: Reports no OTC supplements (Available) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes supplements will indicate her current treatment plan. Example Question: Do you take any supplements?

    • Finding: Asked about allergies

    • Finding: Confirms allergies (Found) Pro Tip: Discerning what’s making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tina’s breathing. Asking Tina what triggers her allergies will indicate, in part, Tina’s health literacy. Example Question: Can you confirm your allergies?

    • Finding: Reports no new allergies (Available) Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing. Example Question: Have you noticed any new allergies?

    • Finding: Followed up on seasonal allergies

    • Finding: Reports no recent seasonal allergy symptoms (Found) Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing. Example Question: Have you been having seasonal allergies?

    • Finding: Reports no current medication for allergies (Available) Pro Tip: Tina’s response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans. Example Question: Are you taking any medication for your allergies?

    • Finding: Asked about diabetes

    • Finding: Reports managing diabetes with diet and exercise in addition to medication (Found) Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans. Example Question: How are you managing your diabetes?

    • Finding: Asked about blood glucose monitoring

    • Finding: Reports checking blood sugar once a day (Found) Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans. Example Question: How often do you monitor your blood glucose?

    • Finding: Checks sugar in the morning (Found) Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans. Example Question: When do you check your blood glucose?

    • Finding: Blood sugar number is usually around 90 (Available) Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans. Example Question: What is your average blood sugar number?

    • Finding: Reports having adequate supplies (Available) Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans. Example Question: Do you have enough supplies to monitor your blood glucose?

    • Finding: Asked about asthma symptoms

    • Finding: Reports no current asthma symptoms (Available) Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Example Question: Do you have any difficulty breathing?

    • Finding: Reports no recent asthma exacerbations (Found) Pro Tip: Asthma severity might change over time for a variety of reasons. Asking Tina about the recent severity of her asthma will allow her to assess her condition. Example Question: Have you had recent asthma symptoms?

    • Finding: Reports last asthma exacerbation was three months ago (Available) Pro Tip: Soliciting a shallow history of a patient’s condition can provide a baseline for comparing an attack, exacerbation, and more regular breathing. Asking about breathing problems can elicit a response about recent troubles. Example Question: When was your last asthma exacerbation?

    • Finding: Asked about headache symptoms

    • Finding: Reports no recent headache (Found) Pro Tip: Soliciting a shallow history of a patient’s condition can provide a timeline for understanding when a patient experiences a condition. Asking Tina if she’s had a headache recently will allow you to assess the frequency of her headaches. Example Question: Have you had a headache recently?

    • Finding: Asked about vision

    • Finding: Reports optometrist visit (Found) Pro Tip: Asking Tina if she has been to an eye doctor will indicate the degree to which she’s seen her vision as something that has needed medical attention. Example Question: Have you been to an eye doctor?

    • Finding: Optometrist visit 3 months ago (Available) Pro Tip: Asking Tina when she last saw an eye doctor will indicate the degree to which she’s seen her vision as something that has needed medical attention. Example Question: When did you go to the eye doctor?

    • Finding: Reports prescription eyeglasses (Found) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Did you get prescription eyeglasses?

    • Finding: Reports that glasses improve overall vision (Found) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Do you like your glasses?

    • Finding: Reports reduction in blurry vision (Found) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Is your vision blurry?

    • Finding: Asked about palpitations

    • Finding: Reports no current palpitations (Found) Pro Tip: Conditions, like palpitations, might change over time. Asking Tina about the frequency and duration of her palpitations recently will allow you to assess the recent severity of her condition. Example Question: Are you having heart palpitations?

    • Finding: Reports no recent palpitations (Found) Pro Tip: Conditions, like palpitations, might change over time. Asking Tina about the frequency and duration of her palpitations recently will allow you to assess the recent severity of her condition. Example Question: Have you been having heart palpitations recently?

    • Finding: Asked about hypertension treatment

    • Finding: Reports that blood pressure responded to diet and exercise changes (Found) Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how she has been treating her hypertension will indicate her treatment plan and the degree to which she complies with it. Example Question: How have you been treating your hypertension?

    • Finding: Asked about GERD

    • Finding: Reports no recent GERD symptoms (Found) Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Example Question: Have you had heartburn recently?

    • Finding: Reports no current GERD symptoms (Found) Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Example Question: Are you having any GERD symptoms?

    • Finding: Reports no current medication for GERD (Found) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes medication for heartburn will indicate her current treatment plan. Example Question: Are you still taking the medication for GERD?

    • Finding: Asked about back pain

    • Finding: Reports no current back pain (Found) Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. Asking Tina about her back pain can help you to treat any symptoms she is experiencing. Example Question: Are you having back pain?

    • Finding: Reports no recent back pain (Found) Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. Asking Tina about her back pain can help you to treat any symptoms she is experiencing. Example Question: Have you had back pain recently?

    • Finding: Asked date of last menstrual period

    • Finding: Last menstrual period was 2 weeks ago (Found) Pro Tip: Finding out when a patient’s LMP was indicates whether she might be pregnant (although this question alone can’t rule out pregnancy). Example Question: When was your last menstrual period?

    • Finding: Asked about menstrual patterns

    • Finding: Reports a period every 4 weeks (Available) Pro Tip: Quantifying the frequency of a patient’s periods is a specific piece of subjective data that can show the severity of a patient’s irregularity. Example Question: How often do you get periods?

    • Finding: Reports that period lasts 5 days (Available) Pro Tip: Quantifying the number of days a period lasts will help you understand what is typical for the patient, and also can indicate related risks for health problems such as anemia. Example Question: How long do your periods last?

    • Finding: Reports some cramping (Found) Pro Tip: Asking a patient for her subjective report on the heaviness of her cramps will help you understand her feelings about her menstrual symptoms. Example Question: Do you still have menstrual cramps?

    • Finding: Reports a medium flow (Available) Pro Tip: Asking about the heaviness of a patient’s periods helps you understand what is typical for that particular patient, and can also indicate related risks for health problems such as anemia. Example Question: Do you still have a heavy menstrual flow?

    • Finding: Asked about weight changes

    • Finding: Reports recent weight loss (Found) Pro Tip: Weight changes can be indicative of underlying health problems or an unhealthy lifestyle. Asking Tina if she’s lost weight might indicate recent changes in health. Example Question: Have you lost weight?

    • Finding: Reports weight loss of about 10 pounds (Available) Pro Tip: Determining the exact amount of weight loss can indicate whether it’s within expected ranges, or extreme, which may indicate an underlying health problem. Example Question: How much weight did you lose?

    • Finding: Reports that weight loss was result of change in diet and increased exercise (Found) Pro Tip: Unintentional weight loss can be a sign of underlying medical conditions or a reflection of unhealthy lifestyle choices. Asking your patient about this can inform your care plan. Example Question: Was the weight loss intentional?

Psychosocial History

    • Finding: Asked about diet

    • Finding: Typical breakfast is fruit smoothie with probiotic yogurt or egg on wheat toast with probiotic yogurt (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for breakfast will illustrate her recent dietary patterns. Example Question: What is your typical breakfast?

    • Finding: Typical lunch is dinner leftovers or tuna or chicken sandwich on wheat bread (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for lunch will illustrate her recent dietary patterns. Example Question: What is your typical lunch?

    • Finding: Typical dinner is vegetables with a protein and brown rice or quinoa (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for dinner will illustrate her recent dietary patterns. Example Question: What is your typical dinner?

    • Finding: Typical snack is carrot sticks or an apple (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for a snack will illustrate her recent dietary patterns. Example Question: What is a typical snack?

    • Finding: Asked about caffeine intake

    • Finding: Reports limiting caffeine since heart and sleep problems (Available) Pro Tip: Asking Tina if she has limited her caffeine intake will indicate her current nutrition habits and whether or not she sees her caffeine intake as a concern. Example Question: Have you limited your caffeine intake?

    • Finding: Reports no coffee drinking (Available) Pro Tip: Finding out specifically if a patient drinks coffee helps you understand what constitutes her typical caffeine intake. Example Question: Do you drink coffee?

    • Finding: Reports only caffeine is diet Coke (Found) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina if she drinks soda will illustrate her recent dietary patterns. Example Question: What caffeinated drinks do you like?

    • Finding: Reports drinking 2 diet Cokes per day (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many diet cokes she drinks a day will illustrate her recent dietary patterns. Example Question: How much soda do you drink a day?

    • Finding: Asked about alcohol intake

    • Finding: Drinks 2-3 nights per month (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many drinks she typically has in a week will illustrate her recent dietary patterns. Example Question: How many nights a week do you drink?

    • Finding: Has 2 or 3 drinks when out with friends (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many alcoholic drinks she typically has at a time will illustrate her recent dietary patterns. Example Question: How many drinks do you have in a sitting?

    • Finding: Orders single drinks (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what size her alcoholic drinks are will illustrate her recent dietary patterns. Example Question: What size are your alcoholic drinks?

    • Finding: Usually orders rum and diet Coke (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what alcohol she usually drinks will illustrate her recent dietary patterns. Example Question: What kind of alcohol do you usually drink?

    • Finding: Asked about exercise

    • Finding: Reports mild to moderate exercise (Found) Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how much exercise she gets can help you to assess her current levels of health and nutrition. Example Question: How much exercise do you get?

    • Finding: Reports walking four or five times a week (Found) Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how many days a week she exercises can help you to assess her current levels of health and nutrition. Example Question: How many days a week do you exercise?

    • Finding: Reports that a typical walk is thirty or forty minutes (Found) Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how long her walks are can help you to assess her current levels of health and nutrition. Example Question: How long are your walks?

    • Finding: Reports weekly swimming at YMCA (Found) Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina what exercise she does can help you to assess her current levels of health and nutrition. Example Question: What exercise do you do?

    • Finding: Reports no asthma exacerbation during exercise (Available) Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how her breathing is when she exercises can help you to assess her current levels of health and nutrition. Example Question: How is your breathing when you exercise?

    • Finding: Asked about relationship status and current sexual activity

    • Finding: Reports no new sexual partners (Found) Pro Tip: Asking Tina if she has any new sexual partners will help you to assess whether or not she engages in high-risk sexual practices. Example Question: Have you had any new sexual partners?

    • Finding: Reports new month-old relationship (Found) Pro Tip: Asking about Tina’s relationship status will help you to understand her current sexual activity and practices. Example Question: Are you currently in a relationship?

    • Finding: Plans to use condoms if sexually active in the future (Available) Pro Tip: Asking Tina whether or not she uses condoms will help you to assess whether or not she engages in high-risk sexual practices. Example Question: Will you use condoms if you are sexually active?

Social Determinants of Health

    • Finding: Asked about education

    • Finding: Reports graduated with accounting degree (Found) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Did you graduate from college?

    • Finding: Asked about work

    • Finding: Reports being hired at Smith, Stevens, Stewart, Silver & Company (Found) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Where do you work?

    • Finding: Reports job title is Accounting Clerk (Found) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: What is your job title?

    • Finding: Reports will start work in 2 weeks (Found) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: When do you start working?

    • Finding: Asked about living situation

    • Finding: Reports currently living at home with mom and sister (Found) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: What is your current living situation?

    • Finding: Reports moving into her own apartment near work in 1 month (Found) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: What are your housing plans?

    • Finding: Asked about support system

    • Finding: Reports strong friendships (Available) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Do you have close friends?

    • Finding: Reports strong familial relationships (Available) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Are you close with family?

    • Finding: Reports church remains a strong support system (Available) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Are you still involved with your church?

Mental Health

    • Finding: Asked about stress

    • Finding: Reports feeling less stress after graduation and passing CPA exam (Found) Pro Tip: Follow-up questions about possible causes or aggravating factors will elicit essential information about a patient’s complaint. When Tina says she is stressed out about the future, it is important to follow up in order to determine if her situation could be contributing to, or causing, her feelings of anxiety. Example Question: Are you feeling stressed?

    • Finding: Reports improved ability to cope with stress (Found) Pro Tip: A patient’s experience with and ability to handle stress is important to your understanding of her stress history as well as its current severity. Asking about coping strategies will give you an understanding of Tina’s support system and usual outlets for dealing with stress. Example Question: How do you cope with stress?

    • Finding: Asked about indicators of depression

    • Finding: Reports no depression (Found) Pro Tip: While a patient with depression does not always know she has it, it is important to ask. If Tina had depression, it could be contributing to her sleep disturbance, or her sleep disturbance could be causing or aggravating or depression. Example Question: Are you feeling depressed?

    • Finding: Reports feeling positive about upcoming life changes (Found) Pro Tip: A broad question asking how a patient feels about her life can help you to assess a patient’s level of mental health, anxiety, or depression. Example Question: How do you feel about your life?

    • Finding: Asked about anxiety

    • Finding: Reports anxiety improved with relief of stressors and passing of time (Found) Pro Tip: Anxiety is a common cause of sleep disturbance, and lack of sleep can also contribute to anxiety issues. If Tina had a history of anxiety, it could be causing or aggravating her current sleep disturbance. Example Question: Are you feeling anxious?

    • Finding: Reports coping well with upcoming life changes (Found) Pro Tip: A patient’s strategies for coping with stress can indicate her experience with and ability to handle stress. An open question about Tina’s usual stress coping strategies will help you assess how experienced she is with stress and how capable she is of coping with it. Example Question: How are you coping with your life changes?

    • Finding: Asked about sleep

    • Finding: Reports no current difficulties falling asleep (Found) Pro Tip: Knowledge of the character of a complaint will aid your diagnosis. In Tina’s case, her sleep quality is important in determining what kind of sleep disturbances she is suffering, as well as possible effects it may have on her daily life. Example Question: Do you still have trouble falling asleep?

    • Finding: Reports sleeping 8 or 9 hours a night (Available) Pro Tip: Asking for the average number of hours of sleep a patient gets in one night will elicit the specific information you need to assess the severity of her sleep disorder. In Tina’s case, she is getting less sleep per night than is considered healthy. Example Question: How many hours do you sleep a night?

Review of Systems

    • Finding: Asked general indicators of health

    • Finding: Reports no recent or frequent illness (Available) Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Example Question: Have you been sick recently?

    • Finding: Reports no fatigue (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like fatigue, details the way her individual symptoms and pain manifest. Example Question: Are you fatigued?

    • Finding: Reports no fever (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like fever, details the way her individual symptoms and pain manifest. Example Question: Have you had fevers?

    • Finding: Reports no chills (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like getting chills, details the way her individual symptoms and pain manifest. Example Question: Have you had chills?

    • Finding: Reports no night sweats (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like night sweats, details the way her individual symptoms and pain manifest. Example Question: Have you had night sweats?

    • Finding: Asked about review of systems for head

    • Finding: Reports no current or recent head problems (Found) Pro Tip: Assessing how a patient feels in the current moment can allow you to juxtapose their chief complaint alongside symptoms they experience. Asking Tina if she currently has a headache solicits information about how she is feeling now. Example Question: Do you have a headache?

    • Finding: Reports no head injury (Available) Pro Tip: People who’ve experienced head injuries are at increased risk for sinusitis. Asking Tina whether she’s ever had a head injury solicits health history information that might explain the cause of her symptoms. Example Question: Have you had any head injuries?

    • Finding: Asked about review of systems for ears

    • Finding: Reports no general ear problems (Found) Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. Example Question: Have you had ear problems?

    • Finding: Reports no change in hearing (Available) Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. Example Question: Has your hearing changed?

    • Finding: Reports no ear pain (Found) Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. Example Question: Have you had ear pain?

    • Finding: Reports no ear discharge (Available) Pro Tip: Ear discharge is the leakage of blood, pus, or wax from the ear and can be the result of a ruptured eardrum, eczema, or swimmer’s ear. Asking whether she’s noticed ear discharge could indicate whether she has a ruptured eardrum. Example Question: Have you had ear discharge?

    • Finding: Asked about review of systems for eyes

    • Finding: Reports no eye pain (Found) Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. Asking Tina whether she is experiencing eye pain solicits information about possible symptoms. Example Question: Have you had eye pain?

    • Finding: Reports no itchy eyes (Available) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Have you had itchy eyes?

    • Finding: Reports no eye redness (Available) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Have you had red eyes?

    • Finding: Reports no dry eyes (Available) Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. Asking Tina if she has dry eyes solicits information about one particular symptom. Example Question: Have you had dry eyes?

    • Finding: Asked about review of systems for nose

    • Finding: Reports no general nose problems (Found) Pro Tip: Infected sinuses can manifest as nose problems. Asking Tina about her nasal symptoms solicits information about her sinuses and possible sinus problems. Example Question: Have you had nose problems?

    • Finding: Reports no change in sense of smell (Available) Pro Tip: Changes in sense of smell could be a symptom of acute sinusitis. Asking Tina if she’s had any changes in her sense of smell indicates whether she might be suffering from acute sinusitis. Example Question: Has your sense of smell changed?

    • Finding: Reports no sneezing (Available) Pro Tip: Infected sinuses can manifest as nose problems. Asking Tina about her nasal symptoms solicits information about her sinuses and possible sinus problems. Example Question: Have you been sneezing?

    • Finding: Reports no nosebleeds (Available) Pro Tip: Nosebleeds are often caused by sinusitis. Asking Tina if she ever gets nosebleeds solicits information about her medical history. Example Question: Have you had nosebleeds?

    • Finding: Reports no sinus pain (Available) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Have you had sinus pain?

    • Finding: Reports no sinus pressure (Available) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Have you had sinus pressure?

    • Finding: Reports no runny nose (Found) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Have you had a runny nose?

    • Finding: Asked about review of systems for mouth and jaw

    • Finding: Reports no current dental problems (Available) Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she’s had any dental problems might indicate a problem area that has caused infection. Example Question: Have you had any recent dental problems?

    • Finding: Reports last dental visit was 5 months ago (Available) Pro Tip: Seeing a dentist regularly can assure that among other things, tooth infections, which can cause sinusitis, do not go untreated. Asking Tina when she last saw a dentist will reveal her health literacy and indicate whether or not her mouth is a problem area. Example Question: When did you last see a dentist?

    • Finding: Reports no general mouth problems (Found) Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Example Question: Do you have any mouth problems?

    • Finding: Reports no change in sense of taste (Available) Pro Tip: Sinusitis can result in decreased smell or taste. Asking if Tina’s sense of taste has changed lately might indicate a sign of sinusitis. Example Question: Has your sense of taste changed?

    • Finding: Reports no dry mouth (Available) Pro Tip: Sinusitis can result in dry mouth. Asking if Tina’s recently had dry mouth might indicate a sign of sinusitis. Example Question: Have you had dry mouth?

    • Finding: Reports no mouth pain (Found) Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she’s had mouth pain might indicate a problem area that has caused infection. Example Question: Have you had mouth pain?

    • Finding: Reports no mouth sores (Available) Pro Tip: In some cases, infection can spread to a cheekbone through an infection in the mouth. Asking Tina if she has any mouth sores might indicate a problem area that has caused infection. Example Question: Have you had mouth sores?

    • Finding: Reports no gum problems (Available) Pro Tip: If left untreated, gum problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her gums solicits information about possible causes of her symptoms. Example Question: Have you had gum problems?

    • Finding: Reports no tongue problems (Available) Pro Tip: If left untreated, tongue problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her tongue solicits information about possible causes of her symptoms. Example Question: Have you had tongue problems?

    • Finding: Reports no jaw problems (Available) Pro Tip: If left untreated, jaw problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her jaw solicits information about possible causes of her symptoms. Example Question: Have you had jaw problems?

    • Finding: Asked about review of systems for neck and throat

    • Finding: Reports no difficulty swallowing (Available) Pro Tip: Difficulty swallowing can indicate sinusitis. Asking Tina if she’s had difficulty swallowing might suggest sinus troubles that she’s experiencing. Example Question: Have you had difficulty swallowing?

    • Finding: Reports no sore throat (Available) Pro Tip: A sore throat can indicate sinusitis. Asking Tina if she’s had a sore throat might suggest sinus troubles that she’s experiencing. Example Question: Have you had a sore throat?

    • Finding: Reports no history of throat problems (Available) Pro Tip: Throat problems are often linked to sinusitis. Asking Tina if she has a history of throat problems will illustrate her medical history in relation to similar concerns. Example Question: Do you have a history of throat problems?

    • Finding: Reports no voice changes (Available) Pro Tip: Sinusitis can often lead to tonsil problems and voice changes. Asking Tina if she has noticed any changes to her voice would indicate whether her symptoms might be caused by sinus problems. Example Question: Have you had voice changes?

    • Finding: Reports no general neck problems (Found) Pro Tip: Neck pain, soreness, or soft tissue damage might result in sinus pain. Asking Tina if she has neck pain is soliciting information about a possible cause of her symptoms. Example Question: Have you had neck pain?

    • Finding: Reports no history of lymph node problems (Found) Pro Tip: Swollen lymph nodes may appear in the neck when an infection is present. Asking Tina whether she has had any problems with her lymph nodes will solicit a history of her condition. Example Question: How are your lymph nodes?

    • Finding: Reports no swollen glands (Available) Pro Tip: Swollen glands may appear in the neck when an infection is present. Asking Tina whether she has had any problems with her glands will solicit a history of her condition. Example Question: Do you have any swollen glands?

    • Finding: Asked about review of systems for respiratory

    • Finding: Reports no current breathing problems (Found) Pro Tip: Asking about how Tina is recently breathing can provide a comparative baseline for assessing Tina’s current condition and previous breathing concerns or conditions. Example Question: Have you had breathing problems?

    • Finding: Reports no wheezing (Available) Pro Tip: Some people who experience chronic asthma may be accustomed to wheezing and, as a result, might not volunteer this information. Asking Tina if she’s been wheezing illustrates how her asthma is presenting. Example Question: Have you been wheezing?

    • Finding: Reports no chest tightness (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like chest tightness, details the way her individual symptoms and pain manifest. Example Question: Have you had chest tightness?

    • Finding: Reports no pain while breathing (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like pain when breathing, details the way her individual symptoms and pain manifest. Example Question: Does it hurt when you breathe?

    • Finding: Reports no coughing (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like coughing, details the way her individual symptoms and pain manifest. Example Question: Have you been coughing?

    • Finding: Asked about review of systems for cardiovascular

    • Finding: Reports no palpitations (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she’s had palpitations specifies the way her individual symptoms manifest. Example Question: Have you had palpitations?

    • Finding: Reports no irregular heartbeat (Found) Pro Tip: Soliciting a shallow history of a patient’s condition can provide a baseline for comparing a current condition, concerns, and medical history. Example Question: Has your heartbeat been irregular?

    • Finding: Reports no easy bruising (Available) Pro Tip: Bleeding or bruising easily means that the capillaries under the skin break easily and often and can be indicative of a severe blood disorder. Asking Tina whether she has been bruising easily allows you to assess other conditions that might be affecting her chief complaint. Example Question: Have you noticed bruising more than usual?

    • Finding: Reports no edema (Available) Pro Tip: When the heart weakens and pumps blood less effective, the resulting fluid that accumulates can lead to edema. Asking Tina whether she’s experienced edema allows you to assess if her heart is pumping less effectively. Example Question: Have you noticed any swelling in your legs?

    • Finding: Reports no circulation problems (Available) Pro Tip: Poor circulation is the result of other diseases like obesity, diabetes, or cardiac conditions. Asking Tina whether she’s experienced poor circulation indicates whether she might suffer from underlying cardiac concerns. Example Question: Do you have circulation problems?

    • Finding: Asked review of systems for gastrointestinal

    • Finding: Reports no nausea (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like nausea, details the way her individual symptoms and pain manifest. Example Question: Have you had nausea?

    • Finding: Reports no vomiting (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like vomiting, details the way her individual symptoms and pain manifest. Example Question: Have you been vomiting?

    • Finding: Reports no stomach pain (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like stomach pain, details the way her individual symptoms and pain manifest. Example Question: Does your stomach hurt?

    • Finding: Reports no constipation (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like constipation, details the way her individual symptoms and pain manifest. Example Question: Do you have constipation?

    • Finding: Reports no diarrhea (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like diarrhea, details the way her individual symptoms and pain manifest. Example Question: Do you have diarrhea?

    • Finding: Reports no flatulence (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like flatulence, details the way her individual symptoms and pain manifest. Example Question: Do you have flatulence?

    • Finding: Asked review of systems for genitourinary

    • Finding: Reports no dysuria (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if it is painful when she urinates can help you to determine the cause of Tina’s symptoms. Example Question: Does it hurt when you urinate?

    • Finding: Reports reduction in nocturia (Found) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has to wake up to urinate can help you to determine the cause of Tina’s symptoms. Example Question: Do you wake up at night to urinate?

    • Finding: Reports no polyuria (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has been urinating more than usual can help you to determine the cause of Tina’s symptoms. Example Question: Do you urinate frequently?

    • Finding: Reports no blood in urine (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if her urine is ever red can help you to determine the cause of Tina’s symptoms. Example Question: Do you ever notice blood in your urine?

    • Finding: Reports no flank pain (Available) Pro Tip: Determining where Tina’s pain is occurring will allow you to most effectively treat her symptoms. Asking Tina if she has flank pain will help you to determine precisely where her pain is located. Example Question: Do you have flank pain?

    • Finding: Reports no vaginal itching or irritation (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like vaginal burning, details the way her individual symptoms and pain manifest. Example Question: Do you experience vaginal burning?

    • Finding: Reports normal vaginal discharge (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like vaginal discharge, details the way her individual symptoms and pain manifest. Example Question: What is your vaginal discharge like?

    • Finding: Asked review of systems for breasts

    • Finding: Reports no general breast problems (Found) Pro Tip: Checking breasts for lumps is important in monitoring for signs of breast cancer. Asking Tina if she’s had problems with her breasts will help you to assess whether she is at risk for breast cancer. Example Question: Do you have any problems with your breasts?

    • Finding: Reports no breast lumps (Available) Pro Tip: Checking breasts for lumps is important in monitoring for signs of breast cancer. Asking Tina if she’s noticed any lumps in her breasts will help you to assess whether she is at risk for breast cancer. Example Question: Have you noticed any lumps in your breasts?

    • Finding: Reports no breast pain (Found) Pro Tip: Checking breasts for lumps is important in monitoring for signs of breast cancer. Asking Tina if she’s had any pain in her breasts will help you to assess whether she is at risk for breast cancer. Example Question: Have you felt pain in your breasts?

    • Finding: Asked review of systems for musculoskeletal

    • Finding: Reports no muscle pain (Available) Pro Tip: The most common causes of muscle pain are strain, overuse, illness, or infection. Asking Tina if she has any muscle pain allows her to describe any pain or symptoms that she is experiencing. Example Question: Do you have muscle pain?

    • Finding: Reports no joint pain (Available) Pro Tip: Joint pain may suggest a major underlying health concern. Asking Tina if she’s experiencing joint pain will allow you to reach a differential diagnosis. Example Question: Do you have joint pain?

    • Finding: Reports no muscle weakness (Available) Pro Tip: Muscle weakness may suggest a major underlying health concern. Asking Tina if she’s experiencing muscle weakness will allow you to reach a differential diagnosis. Example Question: Do you have muscle weakness?

    • Finding: Reports no muscle swelling (Available) Pro Tip: Muscle swelling may suggest a major underlying health concern. Asking Tina if she’s experiencing muscle swelling will allow you to reach a differential diagnosis. Example Question: Do you have muscle swelling?

    • Finding: Asked review of systems for neurological

    • Finding: Reports no dizziness or lightheadedness (Found) Pro Tip: Asking Tina if she’s felt dizzy might indicate whether she is experiencing symptoms of a traumatic brain injury. Example Question: Do you get dizzy?

    • Finding: Reports no vision disturbance (Available) Pro Tip: People with traumatic brain injuries commonly report seeing spots. Asking Tina whether she’s noticed any spots can indicate that she suffered a traumatic brain injury during her accident. Example Question: Do you ever see spots?

    • Finding: Reports no numbness or tingling (Available) Pro Tip: Tingling sensations after a car accident can suggest a herniated disc. Asking Tina whether she’s experiencing tingling sensations might indicate additional musculoskeletal damage caused by the accident. Example Question: Do you ever get tingling?

    • Finding: Reports no loss of coordination (Available) Pro Tip: People with traumatic brain injuries commonly report loss of coordination. Asking Tina whether she’s lost coordination can indicate that she suffered a traumatic brain injury during her accident. Example Question: Do you notice being more clumsy than usual?

    • Finding: Reports no loss of sensation (Available) Pro Tip: Diabetic patients often struggle with neuropathy, especially in the arms, legs, hands, and feet. Patients should be asked about their sensations. Example Question: Do you have a loss of sensation anywhere?

    • Finding: Reports no seizures (Available) Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s had seizures might indicate whether or not she is experiencing symptoms of a traumatic brain injury. Example Question: Have you ever had a seizure?

    • Finding: Reports no problems with balance (Available) Pro Tip: People with traumatic brain injuries commonly report loss of coordination. Asking Tina whether she’s lost coordination can indicate that she suffered a traumatic brain injury during her accident. Example Question: Do you lose your balance often?

    • Finding: Asked review of systems for skin, hair and nails

    • Finding: Reports no rashes (Available) Pro Tip: Chronic or severe skin rashes might require a patient to be seen by a dermatologist. Asking Tina if she has skin rashes will illustrate a skin condition that she might be concerned about. Example Question: Do you get skin rashes?

    • Finding: Reports using sunscreen while exercising outdoors (Available) Pro Tip: Wearing sunscreen is important in protecting the skin from the sun’s powerful UV rays. Asking Tina when she wears sunscreen solicits information about the ways in which she cares for her skin. Example Question: When do you wear sunscreen?

    • Finding: Reports no recent slow-healing wounds (Available) Pro Tip: Slow healing wounds might suggest an infection that requires medical treatment. Asking Tina if she has any wounds that healed slowly solicits information about her health history. Example Question: Have you had any wounds that healed slowly?

    • Finding: Reports improving acne (Found) Pro Tip: Adult acne can suggest stress or changes in hormone levels. Asking Tina if she still has acne solicits information about her overall health. Example Question: Do you still have acne?

    • Finding: Reports some male-pattern hair growth (Found) Pro Tip: Increases in body hair can suggest changes in hormone levels. Asking Tina if she’s experienced an increase in body hair is good practice in soliciting a health history. Example Question: Do you have an increase in body hair?

    • Finding: Reports no changes in moles (Available) Pro Tip: Monitoring moles is key in preventing cancerous growths. Asking Tina if her moles have changed will indicate whether any of her moles are health concerns. Example Question: Have your moles changed?

    • Finding: Reports no sores (Available) Pro Tip: Sores are a skin problem that leave the body vulnerable to infection. Asking Tina if she has any sores will help you to assess her general health. Example Question: Do you have any sores?

    • Finding: Reports no dandruff (Available) Pro Tip: Dandruff is a chronic scalp condition characterized by flaking skin. Asking Tina whether she has dandruff will help in your assessment of her skin conditions. Example Question: Do you have dandruff?

    • Finding: Reports no nail fungus (Available) Pro Tip: Nail fungus might cause discoloration and disfigurement of the nails. Asking Tina if she has nail fungus is important in assessing the health of her nails. Example Question: Do you have nail fungus?

    • Finding: Reports no dry skin (Available) Pro Tip: Chronic or severe dry skin might require a patient to be seen by a dermatologist. Asking Tina if she has dry skin will illustrate a skin condition that she might be concerned about. Example Question: Do you have dry skin?

Rubric

NURS_6521_Week8_Assignment_Rubric

Criteria Ratings Pts
This criterion is linked to a Learning Outcome Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented. Be specific. 20 to >17.8 pts ExcellentThe response accurately and thoroughly summarizes in detail the patient case study assigned, including specific and complete details on each of the three decisions made for the patient presented. 17.8 to >15.8 pts GoodThe response accurately summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented. 15.8 to >13.8 pts FairThe response inaccurately or vaguely summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented. 13.8 to >0 pts PoorThe response inaccurately and vaguely summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented, or is missing. 20 pts
This criterion is linked to a Learning Outcome Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources. 25 to >22.25 pts ExcellentThe response accurately and thoroughly explains in detail how the decisions recommended for the patient case study are supported by the evidence-based literature. … The response includes specific and relevant outside reference examples that fully support the explanation provided. 22.25 to >19.75 pts GoodThe response accurately explains how the decisions recommended for the patient case study are supported by the evidence-based literature. … The response includes relevant outside reference examples that lend support for the explanation provided that are accurate. 19.75 to >17.25 pts FairThe response inaccurately or vaguely explains how the decisions recommended for the patient case study are supported by the evidence-based literature. … The response includes inaccurate or vague outside reference examples that may or may not lend support for the explanation provided or are misaligned to the explanation provided. 17.25 to >0 pts PoorThe response inaccurately and vaguely explains how the decisions recommended for the patient case study are supported by the evidence-based literature, or is missing. … The response includes inaccurate and vague outside reference examples that do not lend support for the explanation provided, or is missing. 25 pts
This criterion is linked to a Learning Outcome What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources. 20 to >17.8 pts ExcellentThe response accurately and thorough explains in detail what they were hoping to achieve with the decisions recommend for the patient case study assigned. … The response includes specific and relevant outside reference examples that fully support the explanation provided. 17.8 to >15.8 pts GoodThe response accurately explains what they were hoping to achieve with the decisions recommended for the patient case study assigned. … The response includes relevant outside reference examples that lend support for the explanation provided that are accurate. 15.8 to >13.8 pts FairThe response inaccurately or vaguely explains what they were hoping to achieve with the decisions recommended for the patient case study assigned. … The response includes inaccurate or vague outside reference examples that may or may not lend support for the explanation provided or are misaligned to the explanation provided. 13.8 to >0 pts PoorThe response inaccurately and vaguely explains what they were hoping to achieve with the decisions recommended for the patient case study assigned, or is missing. … The response includes inaccurate and vague outside reference examples that do not lend support for the explanation provided, or is missing. 20 pts
This criterion is linked to a Learning Outcome Explain any difference between what you expected to achieve with each of the decisions and the results of the decisions in the exercise. Describe whether they were different. Be specific and provide examples. 20 to >17.8 pts ExcellentThe response accurately and clearly explains in detail any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise. … The response provides specific, accurate, and relevant examples that fully support whether there were differences between the decisions made and the decisions available in the exercise. 17.8 to >15.8 pts GoodThe response accurately explains any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise. … The response provides accurate examples that support whether there were differences between the decisions made and the decisions available in the exercise. 15.8 to >13.8 pts FairThe response inaccurately or vaguely explains any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise. … The response provides inaccurate or vague examples that may or may not support whether there were differences between the decisions made and the decisions available in the exercise. 13.8 to >0 pts Poorvaguely explains in detail any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise, or is missing. … The response provides inaccurate and vague examples that do not support whether there were differences between the decisions made and the decisions available in the exercise, or is missing. 20 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. 5 to >4.45 pts ExcellentParagraphs and sentences follow writing standards for flow, continuity, and clarity. 4.45 to >3.95 pts GoodParagraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. 3.95 to >3.45 pts FairParagraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. 3.45 to >0 pts PoorParagraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time. 5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation 5 to >4.45 pts ExcellentUses correct grammar, spelling, and punctuation with no errors 4.45 to >3.95 pts GoodContains a few (1–2) grammar, spelling, and punctuation errors 3.95 to >3.45 pts FairContains several (3–4) grammar, spelling, and punctuation errors 3.45 to >0 pts PoorContains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding 5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list. 5 to >4.45 pts ExcellentUses correct APA format with no errors 4.45 to >3.95 pts GoodContains a few (1–2) APA format errors 3.95 to >3.45 pts FairContains several (3–4) APA format errors 3.45 to >0 pts PoorContains many (≥ 5) APA format errors 5 pts
Total Points: 100

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