Assignment:Academic Clinical History and Physical Note Paper

Assignment:Academic Clinical History and Physical Note Paper

Assignment:Academic Clinical History and Physical Note Paper

History and Physical Note Template

Chief Complaint or Reason for Consult: “Knee stiffness”

History of Present Illness (HPI): P.D. is a 71-year-old White female who was admitted to the medical-surgical unit after she presented with a chief complaint of knee stiffness. She reported that the stiffness began about 8 months ago and has increasingly worsened. She states that she experiences knee stiffness on the right leg, especially when she has walked for a distance. The knee stiffness occurs alongside knee pain. The pain has worsened in severity from mild to moderate. The knee stiffness and pain are more obvious when walking and in the morning. Resting relieves the knee symptoms.  She also reports using a diclofenac gel to relieve the pain, which has relieved it to some degree. She rated the knee pain at 6/1 0.

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Past Medical History: History of obesity from the early 40s. Hyperlipidemia was diagnosed at 56 years. Immunizations are current.

Past Surgical History: Tibia fracture at 33 years from an RTA.

Family History: Father had renal failure, HTN, and Myocardial infarction. Mother died from liver failure. The elder brother has HTN and DM. Third-born has Asthma.  

Social History: P.D. is married and has four children. She lives with her husband and has been married for 45 years. She is a retired high school teacher and currently manages her family’s business. Her hobbies are knitting and baking. She has a history of alcohol use and smoking 1PPD but stopped at 67 years when her BP had elevated.

Allergies: No food or drug allergies.

Home Medications: Vitamin D and Calcium supplements; OTC diclofenac gel.

Hospital Medications: Simvastatin 40 mg QHS.

Review of Systems:

• CONSTITUTIONAL: Reports Limited ability to perform activities and weight gain.
• EYES: Denies blurred or double vision and decline in vision.
• EARS, NOSE, and THROAT: Denies ear pain, discharge, hearing loss, or tinnitus. Denies mucous discharge, nose bleeding, dental pain, difficulty in swallowing, or voice hoarseness.
• CARDIOVASCULAR: Denies SOB, chest tightness, palpitations, or edema.
• RESPIRATORY: Denies SOB, cough, chest tightness, sputum production, or wheezing.
• GASTROINTESTINAL: Denies nausea, vomiting, abdominal pain, tarry stools, or bowel changes.
• GENITOURINARY: Denies dysuria, penile discharge, increased urination, or urinary urgency or frequency.
• MUSCULOSKELETAL: Reports limitations in movement. Reports mild low back pain and knee joint pain and stiffness.
• INTEGUMENTARY: Denies skin rashes, itching, bruises, or lacerations.
• NEUROLOGICAL: Denies headache, paralysis, or gait disturbance.
• PSYCHIATRIC: Denies anxiety or depressive symptoms.
• ENDOCRINE: Denies heat/cold intolerance, acute thirst, or hunger.
• HEMATOLOGIC/LYMPHATIC: Denies bleeding, bruising, or lymph node enlargement.
• ALLERGIC/IMMUNOLOGIC: Denies hives or allergies.

Physical Exam:

• GENERAL APPEARANCE: Patient in no distress. Has an abnormal gait and bending posture. Appropriately dressed and well-groomed. Alert and oriented to person, place, and time.
• VITAL SIGNS: BP- 188/118; HR- 102; RR-20; Temp: 98.42 F; Sp02-99; Wt-220; Ht-5’5; BMI- 36.6
• HEENT: Head: Normocephalic and symmetrical. Eyes: Sclera is white and conjunctiva pink; PERRLA. Ears: Tympanic membranes are shiny and intact. Nose: No nasal secretions or bleeding; The nasal septum is well-aligned. Mouth & Throat: Pink and moist mucous membranes; Tonsillar glands are non-erythematous.
• NECK: Symmetrical, Full ROM, The trachea is midline and well-aligned.
• CHEST: Symmetric; Uniform respirations. Non-tender to palpation
• LUNGS: Lungs clear bilaterally.
• HEART: No edema or neck vein distention; Regular heart rate and rhythm.
• BREASTS: Non-tender with no masses.
• ABDOMEN: Abdomen is soft; Normoactive BS in all quadrants. No epigastric or abdominal tenderness or organomegaly.
• GENITOURINARY: No penile discharge or scrotal swelling.
• RECTAL: Normal sphincter tone. No rectal fissures or ulcerations. The prostate is smooth and non-tender.
• EXTREMITIES: Reduced ROM of the right knee joint. Full ROM of the left knee joint. The right knee joint is warm to touch.
• NEUROLOGIC: Muscle strength at 4/5. Abnormal gait. Speech is clear.
• PSYCHIATRIC: Alert and oriented x 3. Responds to questions appropriately. No suicidal thoughts or ideas. No hallucinations, illusions, or delusions were noted.
• SKIN: Warm and dry, fair skin with no rashes or lesions.
• LYMPHATICS: Lymph nodes are non-palpable.

Laboratory and Radiology Results:

Elevated erythrocyte sedimentation rate (ESR) – 10 mm/h

C-reactive protein (CRP) – 2.0 mg/L

WBC count- 1000/uL

Rheumatoid factor-Negative

X-ray of right knee joint – Reveals narrowing of joint space.

Differential Diagnosis:

Osteoarthritis (OA): OA was the primary diagnosis based on the patient’s symptoms of right knee joint pain, morning knee stiffness, knee stiffness aggravated by walking, Physical findings of a limited range of motion of the right knee joint as well as joint radiography revealing narrowing of joint space, align with OA.

Rheumatoid Arthritis: Rheumatoid arthritis (RA) is a differential diagnosis based on symptoms of morning joint stiffness, joint pain, limited ROM of joints, and limitations in movement (Bullock et al., 2018). Nevertheless, normal levels of ESR and CRP suggest there is no inflammation yet RA is an inflammatory condition. Besides, a negative rheumatoid factor rules out RA as a primary diagnosis.

Plica Syndromes: Plica syndrome is characterized by anterior knee pain localized to the affected plica associated with snapping, clicking, catching, clunking, grinding, or popping inside the knee during flexion and extension (Kuwabara & Fredericson, 2021). This is a differential based on joint pain and limited ROM of the right knee joint.

• Acute and Chronic Medical Conditions:

Obesity

Hyperlipidemia

Osteoarthritis

Treatment Plan:

The patient was admitted in the medical-surgical unit for pain management and observation.

Further Diagnostic Tests: Arthrocentesiswasz ordered within 12 hours of admission to exclude joint infection and inflammatory arthritis.

Medications:  

Inpatient-  Tramadol 100 mg slow IV BD.  

Discharge medications:

Meloxicam- 7.5 mg PO OD for 2 weeks; to alleviate joint pain (Jang et al., 2021).

 Topical Capsaicin- 0.075% TDS for 6 weeks; to decrease pain perception.

Continue Simvastatin 40 mg QHS for hyperlipidemia.

Health Education:

Regular exercises to reduce weight and associated stress on the right knee joint. Reduction of stress on knee joints slows down the loss of cartilage in the joints (Runhaar & Bierma-Zeinstra, 2022).

Nutrition counseling: The patient was advised to take a healthy diet with low caloric content to help in reducing weight, decrease the load on the joints, and increase joint mobilization (Runhaar & Bierma-Zeinstra, 2022).

Heat and cold applications to alleviate joint stiffness and pain.

Consultations: Occupational therapy to educate the patient on joint protection techniques and physical therapy techniques to help the patient perform her activities of daily living (Jang et al., 2021).

Follow-up: The patient was scheduled for a follow-up appointment after two weeks post discharge for evaluation of progress and monitoring of complications. She was advised to seek emergency medical attention in case her symptoms become severe.

Geriatric Considerations:

Ethical and legal considerations for this patient surround the principles of beneficence, nonmaleficence, and autonomy. The practitioner has a duty to prescribe treatments associated with the best outcomes and least side effects for geriatrics. Failing to do so can lead to legal consequences. In addition, the practitioner must involve the patient in treatment planning and respect her decisions to respect their autonomy.

OA is the most common form of arthritis among older adults. It is also one of the major causes of physical disability among adults. Diagnosis and treatment of OA in geriatrics can be challenging due to the wide variety of presentations and also the presence of co-morbidities that can mimic or coexist with OA (Jang et al., 2021). NSAIDs like acetylsalicylic acid, ibuprofen, naproxen, diclofenac, indomethacin, and celecoxib are not recommended as the first line in the elderly due to side effects. They are associated with Gastrointestinal bleeding, renal impairment, fluid retention (worsening edema, hypertension, congestive heart failure), and platelet inhibition. Thus, the patient could not be prescribed an NSAID due to these side effects (Jang et al., 2021). Narcotics are the second-line choice for the elderly and are safer than NSAIDs for geriatrics. Thus, narcotics like codeine, morphine, oxycodone, hydromorphone, fentanyl, tramadol, and meperidine could be prescribed if Meloxicam is not effective in alleviating the patient’s knee pain.  

References

Bullock, J., Rizvi, S. A. A., Saleh, A. M., Ahmed, S. S., Do, D. P., Ansari, R. A., & Ahmed, J. (2018). Rheumatoid Arthritis: A Brief Overview of the Treatment. Medical Principles and practice: international journal of the Kuwait University, Health Science Centre, 27(6), 501–507. https://doi.org/10.1159/000493390

Jang, S., Lee, K., & Ju, J. H. (2021). Recent Updates of Diagnosis, Pathophysiology, and Treatment on Osteoarthritis of the Knee. International journal of molecular sciences, 22(5), 2619. https://doi.org/10.3390/ijms22052619

Kuwabara, A., & Fredericson, M. (2021). Narrative: Review of Anterior Knee Pain Differential Diagnosis (Other than Patellofemoral Pain). Current Reviews in musculoskeletal medicine, 14(3), 232–238. https://doi.org/10.1007/s12178-021-09704-9

Runhaar, J., & Bierma-Zeinstra, S. M. (2022). The challenges in the primary prevention of osteoarthritis. Clinics in Geriatric Medicine, 38(2), 259-271.https://doi.org/10.1016/j.cger.2021.11.012

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Assessment Description

Academic clinical history and physical notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating evidence-based plans of care.

Complete an academic clinical history and physical note based on a patient seen during clinical/practicum. In your assessment, provide the following:

History and Physical Note

Chief complaint/reason for admission/visit/consult.

HPI for the H&P or consult notes.

Medical, surgical, family, social, and allergy history.

Home medications, including dosages, route, frequency, and current medications, if a consultation note.

Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system).

Vital signs and weight.

Physical exam with a complete head-to-toe evaluation. Include pertinent positives and negatives based on findings from head-to-toe exam.

Lab/Imaging/Diagnostic test results (including date).

Assessment and Clinical Impressions

Identify at least three differential diagnoses based upon the chief complaint, ROS, assessment, or abnormal diagnostic tools with rationale.

Include a complete list of all diagnoses that are both acute and chronic.

List the differential diagnoses and chronic conditions in order of priority.

Plan Component Management and Plan Criteria Incorporation

Select appropriate diagnostic and therapeutic interventions based on efficacy, safety, cost, and acceptability. Provide rationale.

Discuss disposition and expected outcomes.

Identify and address health education, health promotion, and disease prevention.

Provide a case summary with ethical, legal, and geriatric considerations. Compare treatment options specific to the geriatric population to nongeriatric adult populations. Consider potential issues, even if they are not evident.

General Requirements

This assignment uses a template. Please refer to the “History and Physical Note Template,” located on the college page of the Student Success Center under the AGACNP tab.

Incorporate at least three peer-reviewed articles in the assessment or plan.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.