Endocrine Metabolic and Nutritional Disorders Case Study Week 9
Ms. Georgia Ann Smith, an 82-year-old white female, presented to the primary care clinic where you are a nurse practitioner provider. The clinic has a full interprofessional team of providers and has a FQHC designation. Ms. Smith is there to establish care as a new patient. She tells you that she has had diarrhea that began about a week ago. Nothing made diarrhea better.
She was having loose stools after eating so she stopped eating yesterday. She just completed Doxycycline after 4 days as it was the only drug in her cabinet other than the Imodium that she began taking along with the Doxycycline. She did not recall what the Doxycycline was for but she remembered feeling better taking it.
She reports she feels better but will not eat again because she does not like having loose stools. She tells you that she has had a stroke years ago, has chronic pain from colon surgery 5 years ago, and is worried about most everything. She takes Tylenol for her pain and worry. Some time ago she had thyroid cancer and that was removed. She did take thyroid medication until about two weeks ago when she ran out and could not get to the pharmacy.
She has frequent falls at home and currently has a spot on her ankle from a fall that will not heal. Then she remembered she has had diabetes since she was in her 50s and for that takes Metformin, 2 500 mg tablets daily. The diabetes made her blood pressure go up so she takes Norvasc 5 mg daily, but not lately as it makes her ankles swell and that is the reason her ankle spot will not heal.
She would like to stop the Metformin as well. She asks if she should go back to the cancer doctor as she has not been in a while. She does not want to go because she does not want to take chemotherapy again. It made her stools loose. But she may need to go because she is having trouble sleeping like she did with the cancer.
She is the lone survivor of her family, parents and one brother, all died of cancer. She had two friends but they also died. She can go to the community center when she needs a bus pass but does not like the bus. That is the reason she stopped going to the clinic. It was a long bus trip. She has little money, she says, because she worked as a gardener for cash. She has her house that she manages alone.
She paid for it when her husband died with his life insurance money. She enjoys being in her home.She brought no health records. Her vital signs at time of arrival are B/P 118/60 H/R 92 R 18 B/S screen 110
Assignment
Complete a Focused SOAP Note for the patient in the case study. Be sure to address the following:
Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding history of present illness and personal and medical history? What details were missing? Was her history realistic? How would you assess its validity? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria, and consider alternative drugs if appropriate. Provide a review of systems.
Objective: What observations did you note from the physical assessment? Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what would rule each differential in or out. Explain your critical thinking process that led you to the provisional primary diagnosis.
Plan: Provide a detailed and realistic treatment plan with the patient after assessing her social determinants of health. Take into consideration all resources present in the FQHC. (If you are not aware, please research by name of clinic.) The plan should address each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions including detailed prescriptions, education, return to clinic for follow up, caregiver support, and any additional planned follow-up visits with other providers.
- Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
- Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.
Solution
Focused SOAP Note
Patient Information:
Initials: G. A. S. Age: 82 years old Sex: Female Race: White
S (subjective)
CC: “I have been having diarrhea that began a week ago.”
HPI: Ms. Smith is an 82-year-old white female who has presented to the primary care clinic to establish care as a new patient. The patient reports that she has had diarrhea that began about a week ago. She further indicates that nothing makes the diarrhea better. She was having loose stools after eating so she stopped eating yesterday.
She just completed Doxycycline after 4 days as it was the only drug in her cabinet other than the Imodium that she began taking along with the Doxycycline. She does not recall what the Doxycycline was for but she states that it made her feel better. According to Ms. Smoth, she is feeling better but will not eat again because she does not like having loose stools.
- Location: Gastrointestinal tract.
- Onset: 7 days ago.
- Character: Not specified.
- Associated signs and symptoms: Loose stools/diarrhea.
- Timing: After eating.
- Exacerbating/relieving factors: Loose stools occur after eating. Nothing makes the diarrhea better.
- Severity: Chronic pain from colon surgery: 7/10.
Current Medications:
- Just completed Doxycycline after 4 days
- Tylenol for chronic pain occurring from a past colon surgery.
- Metformin, 2 500 mg tablets daily for diabetes.
- Norvasc 5 mg daily for high blood pressure (stopped recently).
- Imodium.
- Thyroid medication lastly taken about 2 weeks ago.
Allergies: Ms. Smith believes that Norvasc makes her ankles swell and that is the reason her ankle spot will not heal.
PMHx: Ms. Smith has had a stroke years ago and has chronic pain from colon surgery 5 years ago. Some time ago she had thyroid cancer and that was removed. She has a spot on her ankle from a fall that will not heal. Ms. Smith has had diabetes since she was in her 50s. She also has high blood pressure.
Social and Substance Hx: The patient can go to the community center when she needs a bus pass but does not like the bus. That is the reason she stopped going to the clinic. She has little money, she says, because she worked as a gardener for cash. She has her house that she manages alone. She paid for it when her husband died with his life insurance money. She enjoys being in her home.
Fam Hx: Ms. Smith is the lone survivor of her family, parents, and one brother, all died of cancer. She had two friends but they also died. Her husband is dead.
Surgical Hx: Ms. Smith had a colon surgery 5 years ago.
Mental Hx: Ms. Smith is worried about almost everything. She also has trouble sleeping.
Violence Hx: None reported.
Reproductive Hx: None reported.
ROS
General: The patient has not lost appetite. She denies gaining abnormal weight.
HEENT:
- Head: No head injury reported.
- Eyes: No vision issues reported.
- Ears: Denies hearing loss or ringing of the ears.
- Nose: Denies nasal congestion or runny nose.
- Throat: No throat complications reported.
SKIN: Denies skin dryness, itchiness, or rashes.
CARDIOVASCULAR: No chest pain or chest discomfort reported.
RESPIRATORY: Denies increased fatigue. No cough or shortness of breath.
GASTROINTESTINAL: Reports loose stools/diarrhea. Reports chronic abdominal pain.
GENITOURINARY: Denies burning sensation during urination.
NEUROLOGICAL: Denies numbness in upper and lower limbs.
MUSCULOSKELETAL: Reports frequent falls at home. She has a spot in her ankle from a fall.
LYMPHATICS: Denies enlarged nodes.
PSYCHIATRIC: Reports constant worry and has trouble sleeping.
ENDOCRINOLOGIC: Reports a history of thyroid cancer.
REPRODUCTIVE: Does not report vaginal issues.
ALLERGIES: Suspects Norvasc allergy.
O (objective)
Physical exam:
Vital signs:
B/P 118/60; H/R 92; R 18; B/S screen 110
General: Ms. Smith is alert and attentive. She is well-groomed and keeps eye contact during conversation.
HEENT:
Head: Normocephalic. No evidence of head injury.
Eyes: The patient has a good vision on both eyes.
Ears: Both ears can respond to sound.
Nose: The nasal mucosa is hairy, pink, and most. No congestion observed.
Throat: Not erythematous.
Neck: Ms. Smith can turn her neck sideways without evidence of pain.
Breast: No lumps breasts. No evidence of pain
Lungs: No wheezing. The lungs can expand and contact effectively during inhalation and exhalation.
Cardiovascular/Heart: No heart murmurs; no gallop.
Abdomen: Bowel sounds head. There is evidence of tenderness. Evidence of abdominal pain.
Musculoskeletal: No joint pain. Evidence of muscle stiffness on leg joints.
Neurological: No sensory or motor deficits.
Skin: No erythema, no redness, dryness. Skin is hairy, warm, and smooth.
Diagnostic tests: Colonoscopy.
A (Assessment)
Differential diagnoses:
- Colon cancer (primary diagnosis)
- Gastrointestinal lymphoma
- Ischemic bowel disease
P (plan)
Diagnostic studies:
- Repeat colonoscopy for tissue biopsy. Colonoscopy is believed to have a sensitivity of about 94 % and is therefore effective for detecting colon cancer (Recio-Boiles & Cagir, 2021).
- Perform CT colonography. Colonoscopy and CT colonography tests are conducted to detect cancerous cells (Recio-Boiles & Cagir, 2021).
Referrals to other health-care providers:
- The patient has been referred to an oncologists and to a primary care physician for further evaluation.
- Collaboration with a mental health provider has been established to help provide psychological support.
Pharmacological intervention:
- Begin chemotherapy but after explaining to the patient about its risks and benefits (Recio-Boiles & Cagir, 2021).
Non-pharmacological interventions:
- Consider surgical resection of the colon to remove the cancerous cells (Recio-Boiles & Cagir, 2021).
Patient education and health promotion
- Ms. Smith has been educated about the risks for colon cancer.
- She has been advised to eat a balanced diet rich in yoghurt, calcium, and fiber (Veettil et al., 2021).
- She has also been advised to walk for at least 30 minutes a day to maintain physical fitness (Wang et al., 2021).
Planned follow up visits:
- A follow-up plan has been developed directing the patient to visit the clinic every two weeks for check-up and monitoring.
- The patient’s contacts have been obtained to facilitate continued communication during treatment.
Reflection: The case study has generated one important insight in relation to caring for older adults with metabolic issues. I have learned that diseases of the gastrointestinal tract usually have almost similar symptoms. In this respect, it is highly likely that the clinician will make an inaccurate diagnosis when no proper assessment is done. Therefore, a comprehensive patient evaluation is necessary before initiating treatment. The diagnosis should incorporate elements of both objective and subjective assessments.
References
Recio-Boiles, A. & Cagir, B. (2021). Colon cancer. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470380/
Veettil, S. K., Wong, T. Y., & Loo, Y. S. (2021). Role of diet in colorectal cancer incidence: Umbrella review of meta-analyses of prospective observational studies. JAMA Network Open, 4(2):e2037341. doi:10.1001/jamanetworkopen.2020.37341.
Wang, K., Ma, W., Wu, K., Ogino, S., Chan, A. T., & Giovannucci, E. L. (2021). Healthy lifestyle, endoscopic screening, and colorectal cancer incidence and mortality in the United States: A nationwide cohort study. PLoS Medicine, 18(2): e1003522. https://doi.org/10.1371/journal.pmed.1003522.