Assignment: i-Human Case Study: Evaluating and Managing Cardiovascular Conditions-Harvey Hoya, V6.4PC PL

Assignment: i-Human Case Study: Evaluating and Managing Cardiovascular Conditions-Harvey Hoya, V6.4PC PL

Because cardiovascular conditions are preventable and manageable, it is important that the advanced practice nurse use both their understanding of the cardiovascular system and the impact of patient factors and behaviors that might increase patient risk of such conditions. This critical information can guide you in immediately identifying signs and symptoms that can inform differential diagnoses and lead to the identification of appropriate treatment options and a treatment plan.

For this Case Study Assignment, you will analyze an i-Human simulation case study about an adult patient with a cardiovascular 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.

To prepare:

• Review this week’s Learning Resources. Consider how to assess, diagnose, and treat patients with cardiovascular conditions.
• Access i-Human from this week’s Learning Resources and review this week’s i-Human case study. Based on the provided patient information, think about the health history you would need to collect from the patient.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis.
• Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
• Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
• Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with cardiovascular conditions.

Assignment

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.

By Day 7

Complete and submit your Assignment in i-Human.

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Sample Harvey Hoya SOAP Note

History Taking Questions

• How can I help you today?
• When did your high blood pressure start?
• Do you awaken at night short of breath?
• Why do you wake up?
• When did your headaches start?
• Do you have any allergies, such as medications, food and/or latex, for example?
• Are you taking any prescription medications?
• Can you tell me about any current or past medical problems you have had?
• Do you drink alcohol? If so, what do you drink and how many drinks per day?
• Do you now or have you ever smoked or chewed tobacco?
• Do you have any of the following problems: fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, night sweats?
• Do you experience: chest pain discomfort or pressure; pain/pressure/dizziness with exertion or getting angry; palpitation; decreased exercise tolerance; blue/cold fingers or toes?
• Do you experience: shortness of breath, wheezing, difficulty catching your breath, chronic cough, sputum production?
• Do you have problems with: nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety, bloating?
• When you urinate, have you noticed: pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day or night or any changes in frequency?
• Do you have problems with: muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint swelling or redness, back pain, neck or shoulder pain, hip pain?
• Have you noticed: any bruising, bleeding gums, nose bleeds or other sites of increased bleeding?
• Do you have any of the following: heat or cold intolerance, increased thirst, increased sweating, frequent urination, change in appetite?
• Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, and tremor?
• Do you have any problems with: nervousness, depression, lack of interest, sadness, memory loss, or mood changes, or ever hear voices or see things that you know are not there?
• Tell me about the health of your grandparents, parents, and children.

Problem Statement: Harvey Hoya is a 57 y.o. overweight Hispanic construction worker who presents for evaluation of an elevated blood pressure reading at a recent local health fair. He reports “some” shortness of breath with moderate exertion, intermittent headaches, and interrupted sleep with snoring. Physical examination is notable BP 172/94 L and 178/98 R after 5 minutes of rest; laterally displaced PMI; and funduscopic findings of A-V nicking. Was told he had elevated BP in the past, but took no action. FH is positive for hypertension and related complications.

Physical Examination:

• Vitals:
  • pulse
  • respiration
  • Mental status
  • blood pressure
• HEENT: look in eyes with ophthalmoscope
• HEENT: inspect mouth/pharynx
• Neck: inspect neck
• Neck: palpate neck
• Neck: measure JVP (jugular venous pressure)
• Neck: auscultate carotid arteries
• Chest Wall and lungs: visual inspection – anterior and posterior chest
• Chest wall and lungs: palpate – anterior and posterior chest
• Chest wall and lungs: auscultate lungs
• Heart: palpate for PMI (Point of Maximal Impact)
• Heart: auscultate heart
• Abdomen: visual inspection abdomen
• Abdomen: palpate abdomen
• Abdomen: measure girth
• Extremities: visual inspection extremities
• Abdomen: auscultate abdominal/femoral arteries
• Abdomen: percuss abdomen

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