Evidence-Based Clinical Intervention

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nanznel07

Health Medical

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Using APA format and 3 references use the provided information in the SOAP note attach to respond to all the bullets in the assignment. Use the information in the SOAP note

submit your Evidence-Based Clinical Intervention to the Discussion Area.

Your Evidence-Based Clinical Intervention should be submitted in a Microsoft Word document following APA style and should include the following:

  • The medical problem/diagnosis/disease.
  • Typical presenting signs and symptoms including:
    • Onset, Characteristics, Location, Radiation, Timing, Setting, Aggravating factors, Alleviating factors, Associated symptoms, Course since onset, Usual age group affected
    • Concomitant disease states associated with the diagnosis
  • The pathophysiology of the problem.
  • Three differential diagnoses and the usual presenting signs and symptoms in priority sequence with rationales.
  • Reference to at least two current journal articles that show evidence-based practice as how to best treat this disorder related to the primary differential.
  • The expected outcomes of the intervention.
  • Algorithms if available.
  • A typical clinical note in SOAP format.

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Running Head: SOAP NOTE PATIENT CASE 3983549, WEEK 3 Name: MG Date: 2/16/17 SUBJECTIVE CC: “cough and shortness of breath” HPI: Pt. Encounter Number: 3983549 Age: 52 Sex: Female 1 Running Head: SOAP NOTE PATIENT CASE 3983549, WEEK 3 Patient MG of 52-year-old, female patient, with a medical history of asthma who has not taken any treatment for several years due to the absence of symptoms, comes in this occasion for presenting a cough of three days accompanied by rhinorrhea, sore throat and fever last night. But she says that since last night he has difficulty breathing, dyspnea, cough of moderate intensity accompanied by wheezing. She has difficulty sleeping because of coughing and feels tired. Medications: Protonix 40 mg 1tab daily. GERD PMH Allergies: Penicillin produce Urticaria, rash Medication Intolerances: N/A Chronic Illnesses/Major traumas: GERD, Asthma Hospitalizations/Surgeries: N/A Family History Maternal grandmother COPD, maternal grandfather HTN, paternal grandmother Asthma, paternal grandfather no living dead at 84 years old for Stroke. Father and Mother are healthy. Has two healthy brothers. She has a cousin with medical history of Asthma and Atopic dermatitis. She has three children, the oldest one suffers from asthma, the other two children are healthy. Social History She has a bachelor degree in Business and Administration, works at a bank as a bank loan analyst. She lives with her husband and children in a house of her own, has a good economic situation. Do not smoke, do not drink alcohol, not recreational drugs. ROS General Cardiovascular Denies weight change, fatigue, fever moderate last Denies chest pain, palpitations, PND, orthopnea, night, denies chills, night sweats. edema Skin Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Respiratory She refers cough productive, wheezing, and dyspnea, denies hemoptysis, pneumonia hx, TB Eyes Denies corrective lenses, blurring, visual changes of any kind Gastrointestinal She complaint frequently heartburn, nauseas, burning retrosternal, Abdominal pain, Globus sensation after meals. She denies constipation, hepatitis, hemorrhoids, black tarry stools Ears Denies ear pain, hearing loss, ringing in ears, discharge Genitourinary/Gynecological Denies urgency, frequency burning, change in color of urine. No vaginal discharge. G3P3A0. No oral Contraception, she uses Natural family planning 2 Running Head: SOAP NOTE PATIENT CASE 3983549, WEEK 3 Nose/Mouth/Throat Denies sinus problems, dysphagia, nose bleeds. She has nasal discharge, clear and throat pain Musculoskeletal Denies back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis Breast Denies SBE, lumps, bumps or changes Neurological Denies Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells Psychiatric Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx Heme/Lymph/Endo Denies bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance OBJECTIVE Weight 148 BMI 23.9 Temp 98.9 BP 136/76 Height 5’6” Pulse 110 Resp 30 General Appearance Healthy appearing adult female in no acute respiratory distress and anxious. Alert and oriented; answers questions appropriately. Skin Skin is white, warm, dry, clean and intact. No rashes or lesions noted. HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is erythematous and without exudate. Teeth are in good repair. Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema. Respiratory Symmetric chest wall. Respirations regular, labored; lungs expiratory wheezes in both lung more intense in bilateral bases to auscultation. Gastrointestinal BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. Genitourinary Bladder is non-distended; no CVA tenderness. External genitalia reveal coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar and vaginal examination done. Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room. Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal. Psychiatric Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Lab Tests CBC: WBC 11000 Neut: 68 Lymp:36 Mono: 7.7 Eos: 8 Chest x-ray: shows bilaterally increased air volume, low diaphragms, wide diaphragmatic angles, cardiac silhouette normal. No signs of condensation pulmonary, no pneumothorax no pleurisies. 3 Running Head: SOAP NOTE PATIENT CASE 3983549, WEEK 3 Special Tests N/A Diagnosis 1. 2. 3. 4. Asthma: Asthma is a chronic inflammation of the airways in response to certain stimuli leading to an exaggerated bronchial response and hyperproduction of mucus. This disease is characterized by reversible attacks characterized by cough, wheezing and dyspnea. Asthma attacks are triggered by many factors including infections, allergens, exercise, and sudden changes in temperatures. Asthma is the most common chronic respiratory disease prevalent in all age groups. Asthma has a large genetic component by which we see it frequent in individuals of the same family group. On physical examination, these patients during the asthma attack are anxious with labored breathing, coughing and wheezing. At the physical examination, we find hyper resonant lungs and wheezes on auscultation. Although chest x-ray does not give a definitive diagnosis, it can show signs of bilaterally increased air volume, low diaphragms, wide diaphragmatic angles. As well as helps to rule out other diseases that can produce cough and wheezes. COPD: COPD is an obstructive airway disease associated with abnormal inflammatory responses. This disease is defined clinically by persistent cough for more than three months for two consecutive years with periods of acute exacerbations. In COPD, the limitation of airflow is caused by a combination of small airway disease and parenchymal destruction. The main risk factor is the environmental factor which is composed of cigarette smoke and environmental dust. Although this disease is treatable, it has a chronic and often irreversible course. The clinic presentation is very important the toxic habits, the occupation of the patient and the form of presentation which the most common complaint of these patients is dyspnea on exertion. At the physical examination, we can find hyperinflation sings such as anteroposterior diameter increase of the thorax, increase of the intercostal spaces, hyperresonance to the percussion of the thorax, decrease of the transmission of respiratory sounds and we can hear wheezes but these are more significant in the asthma. El diagnostic at the physical examination we can find hyperinflation sings such as anteroposterior diameter increase of the thorax, increase of the intercostal spaces, hyperresonance to the percussion of the thorax, decrease of the transmission of respiratory sounds and we can hear wheezes but these are more significant in the asthma. The diagnosis of COPD is confirmed by means of spirometry since it is considered the gold standard for the diagnosis of COPD. Congestive Heart failure: The typical symptoms of heart failure are dyspnea and fatigue. Dyspnea in heart failure is paroxysmal nocturnal dyspnea and orthopnea as well as shortness of breath with exercise or at rest. Patients generally present with fatigue and loss of appetite. The symptoms of jugular venous distention, cardiac enlargement, and a third heart sound (S3), are specific for heart failure and are not present in our patient. We can also find edemas in inferior members. The patient with Heart failure has no bronchial obstruction therefore these patients do not present wheezes in the lungs although there is a picture called cardiac asthma which can manifest with persistent cough, wheezing or bronchospasm. Pulmonary Embolism: Pulmonary embolism manifests abruptly of pleuritic chest pain, shortness of breath, and hypoxia. Symptoms may also manifest with progressive dyspnea. Most of the time EP occurs as a complication of DVT in lower limbs. Among the symptoms and signs we can find, tachypnea, tachycardia, cyanosis, rales, S 3 or S 4 gallop and rales in the lungs. In a large percentage of patients, we can find symptoms of thrombophlebitis. o 1. Final Diagnosis Asthma: This is my final diagnostic due to patient has medical history of Asthma, she has 4 Running Head: SOAP NOTE PATIENT CASE 3983549, WEEK 3 familiar history of Asthma in several family’s members. The HPI show typical symptoms of asthma such as SOB, cough and wheezes and the physical exam show expiratory wheezes in both lungs. 2. Respiratory infection; For cough, sore throat, fever and nose discharge maybe viral etiology. 3. GERD: Medical antecedents ▪ PLAN including Education o Plan: ▪ Medication Albuterol MDI: 90 g/puff, 200 puffs/canisters 2 puffs every 4-6 hours, as needed for symptoms. Theophylline 300 mg extended release twice a day for 7 days Pantoprazole 40 mg 1tab daily by mouth. ▪ Education a- bcd- ▪ Non-medication treatments a- b▪ Dust mite allergens: Wash bedding weekly in hot water and dry it in a hot dryer. Encase pillows and mattresses in airtight covers. Remove carpets, especially from your bedroom. Avoid use of fabric-covered furniture, especially for sleeping. Animal fur allergens: Avoid keeping house pets, or at least don’t allow them in sleeping areas Smoke allergens: Avoid all of the following: Smoking, contact with tobacco smoke, smoke from wood-burning stoves or fireplaces If cold air causes symptoms, wear a scarf over your mouth and nose if you must go outside during the winter. Avoid vigorous exercise if this causes asthma symptoms Diet for GERD avoid spice food, fat foot an avoid eat before go to sleep. Also avoid any foot that you have found a food that causes an allergic reaction Follow up Next appointment for next day to evaluate if patient is stable. o References: Butaro, T. M., Trybulsky, J., Bailey, P.P., & Sadberg-Cook, J. (2013). Primary Care A Collaborative practice. (4th Ed.). [Vital Source digital version]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/978-0-323-07501-5/cfi/0!/4/2/2@0:55.7 5 Running Head: SOAP NOTE PATIENT CASE 3983549, WEEK 3 Cash, J. C & Cheryl, A. G. (2014). Family practice Guidelines. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9780826168757/cfi/0!/ Goolsby, J. M., & Grubbs, L. (2014). Advanced Assessment: Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. [Vital Source digital version] https://digitalbookshelf.southuniversity.edu/#/books/9780803645011/cfi/0 Quellette, D. R. (2016). Pulmonary Embolism. Retrieved from http://emedicine.medscape.com/article/300901-overview 6
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Submission date: 20-Jan-2018 07:22PM (UT C-0500)
Submission ID: 904746866
File name: Evidence_based_program.docx (25.8K)
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https://www.studypool.com/discuss/5538905/evidence-basedclinical-intervention
ORIGINALITY REPORT

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Running head: EVIDENCE-BASED CLINICAL QUESTION
Topic: Evidence-Based Clinical Question
Student name:
Instructor name:
Course name:
Date:

Evidence-Based Clinical Question

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The report dwells on a picot question intended to reveal the evidence that's needed when
determining the best intervention to suggest to couples and families affected by the menace.
Firstly, Hemochromatosis refers to a situation where iron gets excessively absorbed from the
digestive tract. The absorbed iron saturates the bodily tissues which create an overload of iron in
the body. The signs related to the infection include joint pains, sexual dysfunction, skin
coloration changes, weaknesses, diabetes mellitus and heart failure. The identification and early
treatment of the condition could reduce the risks of the complications. The treatment of
Hemochromatosis requires blood removal from the body because they contain lots of iron than
needed.
Hemochromatosis Causes
According to Everson, and Weinberg, (2013), hemochromatosis occurs as a result of
extreme iron absorption, though further studies get conducted in the area. From a genetic
perspective, chemical processes within the human body determine the amount of iron absorbed.
The method of iron absorption takes place through the HFE, and gene mutation could make lots
of metal consumed. C282Y is the most common mutation form which also occurs in those with
Hemochromatosis. The genes come from the parents, one from the mother and father
respectively. Other mutation processes related to Hemochromatosis are still on the verge of study
and are yet to get established. The report suggests that offering advice to couples in the age
bracket from 25 to 43 years could reduce their possibility of getting children. Reports emerged
that certain people with at least two C282Y genes don't absorb lots of iron into their bloodstream.
The report found that Hemochromatosis commonly inherited amongst the white. The
United States alone reveals that at least 15 in 1000 people get born with the condition; however,
others don't even know that they have the state. It's advisable that those with Hemochromatosis

Evidence-Based Clinical Question

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must involve their family members in diagnosis to rule out the possibility of them being victims.
The study found that at least 10% of the white people are carriers of C282Y mutant gene and
they express no symptoms of the condition.
Hemochromatosis Symptoms
The Hemochromatosis symptoms occur among those with both the C282Y and HFE gene
mutations. The report acknowledged that studies on the relationships between iron and the
mutant gene are underway. The necessity for the study is because those with two sets of the
mutation don’t experience iron overload.
According to Everson, and Weinberg, (2013), hemochromatosis existed in the body for
years before one would notice and seek medical attention. However, the notion changed, and
peo...


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Excellent resource! Really helped me get the gist of things.

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