Title of Plan of Care Name South University Online Faculty ✓ Solved
Patient Initials ______
Subjective Data:
Chief Complaint: (In patient’s exact words)
History of Present Illness: (Analysis of current problems in chronological order using symptom analysis: onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated symptoms and treatments tried).
PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history, obstetric and sexual history).
Significant Family History: (Includes family members and specific inheritable diseases).
Social History: (Includes home living situation, marital history, cultural background, health habits, lifestyle/recreation, religious practices, educational background, occupational history, financial security, and family history of violence).
Review of Symptoms: (Review each body system - This section you should place POSITIVE for… information in the beginning then state Denies…).
- General:
- Integumentary:
- Head:
- Eyes:
- ENT:
- Cardiovascular:
- Respiratory:
- Gastrointestinal:
- Genitourinary:
- Musculoskeletal:
- Neurological:
- Endocrine:
- Hematologic:
- Psychologic:
Objective Data:
Vital Signs:
BP - ; P ; R ; T ; Wt. ; Ht. ; BMI.
Physical Assessment Findings: (Includes full head to toe review)
HEENT: Lymph Nodes: Carotids: Lungs: Heart: Abdomen: Genital/Pelvic: Rectum: Extremities/Pulses: Neurologic:
Laboratory and Diagnostic Test Results: (Include result and interpretation.)
Assessment: (Include at least 3 priority diagnoses with ICD-10 codes. Please place in order of priority.)
Plan of Care: (Addressing each diagnosis with diagnostic and therapeutic management as well as education and counseling provided).
Paper For Above Instructions
Plan of Care
The patient in this case is a 45-year-old male presenting with multiple chronic health issues requiring a comprehensive plan of care. The following sections detail his subjective and objective data, assessments, and planned interventions.
Subjective Data
The patient reports, "I feel weak and dizzy often, and I have trouble breathing after minimal exertion." He is particularly concerned about his weight loss, which he states has been approximately 10 pounds over the past month without any dietary changes. The history of present illness shows that he has experienced increasingly severe shortness of breath, especially while walking up stairs (onset gradually worsening over the past three months). The patient denies any chest pain but reports occasional palpitations.
His medical history is notable for hypertension and hyperlipidemia, for which he is currently taking lisinopril and atorvastatin. He has a known allergy to penicillin. Other major medical problems include obstructive sleep apnea, controlled with continuous positive airway pressure (CPAP) therapy.
Family and Social History
Significant family history includes a father with coronary artery disease and a brother diagnosed with type II diabetes. His social history reveals that he is married, lives in a stable household, and has two children. He reports a sedentary lifestyle, with little recreational activity, and has expressed a desire to improve his dietary habits. He also mentions financial stress due to medical expenses from prior hospitalizations.
Review of Symptoms
The review indicates positive findings in the respiratory system, as per the patient complaints of shortness of breath; however, he denies symptoms associated with gastrointestinal, genitourinary, and neurological systems. Vital signs upon assessment were as follows: BP 130/80 mmHg, P 78 bpm, R 20 breaths/min, T 98.6°F, Wt 230 lbs, Ht 5'10", BMI 33.1 (obesity).
Objective Data
A thorough physical examination reveals mild wheezing bilaterally upon auscultation, with no signs of cyanosis. Cardiac examination is unremarkable. The rest of the physical exam demonstrates no acute distress.
Relevant lab results include an elevated B-type natriuretic peptide (BNP) level, suggestive of heart failure, and chest X-ray shows signs of mild pulmonary congestion.
Assessment
Approximately three priority diagnoses are established based on the above findings:
- Chronic obstructive pulmonary disease (COPD) – J44.9
- Obesity hypoventilation syndrome – G47.30
- Hypertensive heart disease – I11.9
Plan of Care
The following is the proposed plan of care addressing the identified diagnoses:
Diagnostic and Therapeutic Management
1. COPD Management: Initiate a bronchodilator therapy and consider inhaled corticosteroids to manage and control inflammatory processes. Schedule a follow-up pulmonary function test (PFT) to monitor lung capacity.
2. Weight Management: Refer the patient to a dietitian for counseling on caloric intake and an exercise program tailored to his ability. Goal weight loss should be set at one to two pounds per week through diet and increasing physical activities.
3. Hypertension Control: Monitor blood pressure regularly and adjust antihypertensive medications as needed. Encourage lifestyle modifications such as a low-sodium diet.
Patient Education and Counseling
Education on recognizing exacerbation of symptoms, the importance of medication adherence, and the proper use of a peak flow meter were discussed. Additionally, encourage smoking cessation and provide resources for stress management considering the financial strains mentioned by the patient.
References
- Centers for Disease Control and Prevention. (2022). Health effects of overweight and obesity.
- World Health Organization. (2021). Obesity and overweight.
- American Lung Association. (2020). COPD management.
- National Heart, Lung, and Blood Institute. (2021). Your guide to asthma management.
- American Diabetes Association. (2021). Standards of medical care in diabetes.
- National Institute of Diabetes and Digestive and Kidney Diseases. (2022). Obesity.
- Chaudhry, R., & Watson, K. (2021). Effective weight management strategies for chronic illnesses. Journal of Health Management, 12(3), 201-209.
- Smith, R. J., & Mason, L. (2020). The pathophysiology of obesity hypoventilation syndrome. Respiratory Medicine, 10(2), 150-158.
- Cardiovascular Disease Risk Factors. (2021). National Institutes of Health.
- Harvard Medical School. (2020). Managing hypertension.