Patients frequently present with complaints of pain, such as chronic back pain. They often seek medical care with the intent of receiving drugs to manage the pain. Typically, for this type of pain, narcotic drugs are often prescribed. This can pose challenges for you as the advanced practice nurse prescribing the drugs. While there is a process for evaluating back pain, it can be difficult to assess the intensity of a patient’s pain since pain is a subjective experience. Only the person experiencing the pain truly knows whether there is a need for drug treatments.
For this Case Study Assignment, you will analyze an i-Human simulation case study about an adult patient with a musculoskeletal condition. Based on the patient’s information, you will formulate a differential diagnosis, evaluate treatment options, and create an appropriate treatment plan for the patient.
As you interact with this week’s i-Human patient, complete the assigned case study. For guidance on using i-Human, refer to the i-Human Graduate Programs Help link within the i-Human platform.
Management Plan Template– must include
*Primary Diagnosis (Acute Gout with tophus) with ICD-10 code, rationale and resources. Include CPT codes, and any procedural codes, including nurse lab draws, vaccinations given, biopsies, etc...
Diagnostics Performed (need cpt codes):
*Guidelines used to develop this primary diagnosis.
*Differential diagnoses with rationale and resources. 3-5 Ddx required, unless well visit. Medications including OTC, dosage and education,additional ancillary tests needed, referrals and
Differential dx :
*Social Determinants of Health to consider, Health
*Promotion and Pt risk factors –
Must use 3 scholarly references
Primary diagnosis: Primary Diagnosis: Essential hypertension, I10. Elevated BP above normal range x 2 occasions substantiates diagnosis of hypertension, likely Essential HTN, given lack of identifiable secondary cause. Guidelines: Guidelines for Essential hypertension based on ACC/AHA 2017 and the ESC/ ESH 2018, which recommends at least two office measurements on at least two separate occasions with readings above 130/80mmhg that is necessary to diagnose hypertension (Whelton et al., 2022). There is also an additional history of risk factors such as smoking, alcohol use, overweight, sedimentary lifestyle, and a family history of cardiovascular diseases such as hypertension.
Differential diagnoses include:
Rationale: The patient has snoring and sleep disturbance symptoms.
According to Arredondo et al. (2021) OSA is associated with risk factors such male gender, alcoholism and obesity. This diagnosis is less likely due to absence of other critical symptoms such as daytime somnolence, narcolepsy, and cognitive impairment as outlined by Arredondo et al. (2021)
Rationale: This differential is indicated by the shift apex beat to 5th ICS 4 cm lateral to the midclavicular line; indicating possible cardiomegaly. However, a diagnosis of HF is less likely because the patient does not meet the Framingham Diagnostic Criteria for Heart Failure, despite having risk factors such as hypertension, obesity and smoking (Malik et al., 2023).
Rationale: A history of long-term smoking may result in COPD.
However, COPD is a less likely diagnosis due to lack respiratory symptoms, such as respiratory distress in acute exacerbations, barrel chest, Central cyanosis Accessory respiratory muscle use, Prolonged expiration, Wheezing and Pursed-lip breathing among others non respiratory symptoms (Agarwal et al., 2023).
The primary diagnosis is Essential hypertension, I10, based on harmonized guidelines of ACC/AHA 2017 and the ESC/ ESH 2018, which recommends at least two office measurements on at least two separate occasions with readings above 130/80mmhg that is necessary to diagnose hypertension (Whelton et al., 2022). There is also an additional history of risk factors such as smoking, alcohol use, overweight, sedimentary lifestyle, and a family history of cardiovascular diseases such as hypertension.
Management plans include:
Pharmacological Therapy: The mainstay treatment of essential hypertension endorsed by ACC as well as ESC/ ESH includes the use of a combined therapy with ACEi or an ARB along with a thiazide diuretic and calcium channel blocker simultaneously (Whelton et al., 2022). The medication can also be a monotherapy using a stepwise up-titration to maximum dosage before instituting a second drug (Whelton et al., 2022). This patient would benefit from a combined therapy of Enalapril 5mg PO daily and Amlodipine 5mg PO daily. Starting low doses and titrating according to blood pressure response is important. The target blood pressure is below 130/80mmhg and elimination of other symptoms such as headache and poor sleeping (Whelton et al., 2022).
Additional Evaluation: The patients also need a comprehensive metabolic and lipid panel to evaluate metabolic syndrome. Additionally, it would be feasible to do a two-lead ECG, CBC, ESR, creatinine, eGFR, electrolytes, HbA1c, and thyroid profile (Iqbal & Jamal, 2021).
Referral: The patient would benefit from a referral to a dietician to encourage a DASH diet high in fruits/veggies, low-fat dairy, and low sodium.
Non-Pharmacological Therapy: The patient needs lifestyle modification; they should be encouraging moderate intensity exercise most days of the week, such as walking for 3omin or more. They should also be encouraged to consider weight loss nutritional support by the dietician counseling. The patient should be encouraged to stop smoking cessation and quit alcohol through counseling. They should be made aware of the effects of smoking in the development of cardiovascular diseases and other respiratory comorbidities such as lung cancer and COPD.
Patient Education: The patient should be educated on HTN management; it should be clearly stated that hypertension is a chronic condition and drugs should not be stopped when blood pressure normalizes (Carey et al., 2022). They should be notified about the importance of adherence because poor adherence or defaulting is associated with complications such as stroke and other CVD risks. Should be advised against poor feeding, like eating junk and fast foods, as they are associated with cardiovascular risks (Carey et al., 2022).
Follow-up: The patient needs a follow-up in 1 month to evaluate medication tolerance and lifestyle changes. If blood pressure is normal and stable and drug side effects are addressed along with good progress in lifestyle modification, the patient can be scheduled for a 3-month follow-up period (Carey et al., 2022). However, the patients should be encouraged to have blood pressure checks regularly and seek healthcare in case of persistently high readings. The patients should also seek healthcare services if they experience syncopal episodes, chest pain, or severe headaches (Carey et al., 2022).
SDOH: The Patient likely has barriers to accessing healthy food and safe exercise spaces, contributing to HTN risk. Encourage checking for local community resources for counseling on cardiovascular diseases (USPSTF, 2020).
Carey, R. M., Moran, A. E., & Whelton, P. K. (2022). Treatment of Hypertension: A Review. JAMA, 328(18), 1849–1861. https://doi.org/10.1001/jama.2022.19590
Iqbal, A. M., & Jamal, S. F. (2021). Essential Hypertension. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539859/#:~:text=The%20current%20definition%20of%20hypertension
Lin, X., & Li, H. (2021). Obesity: Epidemiology, Pathophysiology, and Therapeutics. Frontiers in Endocrinology, 12(1). https://doi.org/10.3389/fendo.2021.706978
Nguyen, U. T. V., Bhuiyan, A., Park, L. A. F., Kawasaki, R., Wong, T. Y., Wang, J. J., Mitchell, P., & Ramamohanarao, K. (2013). Automated quantification of retinal arteriovenous nicking from color fundus images. Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual International Conference, 2013, pp. 5865–5868. https://doi.org/10.1109/EMBC.2013.6610886
USPSTF. (2020, November 24). Recommendation | United States Preventive Services Taskforce. Www.uspreventiveservicestaskforce.org. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/healthy-diet-and-physical-activity-counseling-adults-with-high-risk-of-cvd
Whelton, P. K., Carey, R. M., Mancia, G., Kreutz, R., Bundy, J. D., & Williams, B. (2022). Harmonization of the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension Blood Pressure/Hypertension Guidelines: Comparisons, Reflections, and Recommendations. Circulation, 146(11), 868–877. https://doi.org/10.1161/circulationaha.121.054602
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