As the Nurse Practitioner for the case study patient, Evaluate the subjective and objective information provided in the case study scenariobelow.The first identify all pertinent positive and, negative information and list the needed missing information.Then create a differential diagnosis list with at least 3 possibly actual diagnoses based on your findings.The second part is to create a plan utilizing clinical practice guidelines for the priority diagnosis.Be sure to utilize template, in-text citations, and provide full reference citation at the end of your response.
Case study Information:
C.C. “I can’t sleep.”HPI: 97 y.o. F presented to HU Clinic for follow-up trouble sleeping. First noticed the sleep dysfunctionwhen she was hospitalized three months ago with acute exacerbation of heart failure. Since then shehas been waking up frequently at night. She denies trouble lying flat, her weight has been stable, and noswelling. She denies CP or SOB. She reports not having issues with initiating sleep, but it is maintainingsleep. She wakes up and lays in bed for hours until she falls back to sleep. She has noticed this causesher to have increased daytime sleepiness. She is wanting to try something to help her sleep since she isfrustrated at this point and it has never been an issue.Past medical history: HFpEF, HTN, HLD, CADAllergies: Cephalosporin, PCN, Carbapenems.Medications: Metoprolol Succ 50 mg PO daily. Lasix 40 mg PO daily. Atorvastatin 40 mg PO daily. ASA81 mg PO daily. Amlodipine 10 mg PO daily. Lisinopril 10 mg PO daily. Tylenol 500 mg PO Q6H asneeded for generalized pain.Social history: Lives in assisted living. Usually active walking laps around the apartment complex with a rollingwalker. Has four adult children who live close by and visit her weekly. She denies tobacco, alcohol, andillicit drug use.Family history: Was adopted does not know biological family.Health Promotion: UTD on routine screening, prevention, and vaccinations. Last PCP appt 1 month agofor follow-up after hospitalization: CBC, BMP, TSH, BNP, Lipid panel, EKG check and in normal limits.Review of systemGeneral – Denies fever, chills or dizziness. She has been sleeping more during the day. Goes to bedaround 8PM without issues, then wakes around 12AM. She lays in bed until around 4AM and usuallyfalls back to sleep.Skin – denies rash and skin ulcerHEENT -denies hearing and vision loss, headacheNeck – denies swelling and stiffnessCardiovascular – denies chest pain/tightness palpitations, heart racingPulmonary – denies shortness of breath, coughGastrointestinal – denies abdominal pain, nausea, vomiting, and diarrhea. No change in appetite, weightgain or loss.Genitourinary – Reports increase urination in the morning with Lasix but denies burning or blood.Peripheral vascular – denies discoloration and edemaMusculoskeletal – denies muscle and joint acheNeurological – denies confusion, memory loss, numbness or tingling. Denies lightheadedness or feelingof faintness. Psychological – denies anxiety, depression and confusion. Feels stressed from not sleepbecause it is affecting her during the day and not walking daily like she typically does. Endocrine: Deniesweight loss or weight gain. Hematologic: Denies bruising or bleeding easily.Objective DataVital signs:.T- 98.6 F, HR- 59 RR- 19, BP – 132/76 mmHgPulse ox – 96%, Wt.: 165 lbs. Ht 62 inGeneral appearance: No acute distress, well-nourished and cleanly kept.HEENT: Normocephalic, face symmetrical. PERRLA. Auditory canal intact and clear. Hearing intact. Oralmucosa moist without ulcerations or lesions. Uvula midline. Dentures. Neck: Non-palpable, non-tenderlymph nodes. Thyroid gland without enlargement or nodules.CV: Regular rate, rhythm, S1/S2.Lungs: Bilaterally clear to auscultation, no adventitious sounds. No clubbing noted. Abdomen: Bowelsounds present in all four quadrants, abdomen is soft and non-tender, no guarding, no rebound, noenlargement, or organomegaly noted.Genitourinary: No suprapubic or CVA tenderness.PV: B/L, equal +2 distal pulses. Capillary refill less than 3 seconds. No swelling, erythema or ulcerationson exam. No edema.MSK: Active and passive ROM within normal ranges. Uses rolling walker without issues.Neuro: Alert and oriented to person, place, date and situation. Appropriate conversation. Strength 5/5throughout. Cerebellar Rapid alternating movements intact.Psychiatric: Behavior appropriate for the age. Thoughts are coherentNeurological: Alert, oriented, cooperative. Speech is clear. Oriented to person, place, and time.
