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Week 4 DB NURS 681 copy - Physical Assessment
Advanced Physical Assessment (NURS 681)
West Coast University
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Week 4 DB NURS 681
Case 2: A 29-year-old newly immigrated woman complains of weakness, shortness of breath, cough, and night sweats for the past month.
In this case the questions I have for this patient include. Have you been around anyone else that is not feeling well? Does anyone at home have these symptoms? What country did you immigrate from? How would you describe your cough dry? productive? Are you coughing up any blood or phlegm? Have you had a fever? Have you had any recent respiratory infections? Does it hurt to breath or cough? Is there anything that makes your symptoms worse? Is there anything that makes your symptoms better? Do you have any wheezing? Do you have any nasal congestion or runny nose? Have you experienced unexpected weight loss? Have you been around anyone with tuberculosis, or have you ever had a positive tuberculosis test?
Diagnostic tests: Chest x-ray, CBC, and a TB skin test[ CITATION CDC224 \l 1033 ].
Physical examination: Physical examination would include respiratory assessment including lung sounds, symmetry of chest during respirations, look for any accessory muscle use. Check body temperature for any fever.
ROS:
General- Positive for fever, chills, and weight loss.
Cardiovascular – Denies chest pain.
Respiratory- C/O shortness of breath and productive cough.
Objective:
General- A 29-year-old female presents to the clinic in no acute distress. Alert and oriented x3. Maintained eye contact and answered questions appropriately.
Heart- Denies chest pain or palpitations.
Lungs- + dyspnea, bilateral crackles in lower lobes.
Assessment:
Pertinent positives- Cough, shortness of breath, fever, night sweats and recent immigration status.
Pertinent negatives- No other symptoms.
Differential diagnoses-Pneumonia due to prolonged cough, fever, and shortness of breath.
Tuberculosis- due to physical examination, prolonged cough, shortness of breath, night sweats and recent immigration status.
Diagnosis- Tuberculosis
Plan:
Medication- CDC recommends a 4-month RPT-MOX regimen in the treatment of active TB that is not drug resistant in those 12 years of age and older. This is composed of 8 weeks of daily treatment with RPT(high dose rifapentine), MOX (moxifloxacin), INH (isoniazid), and PZA (pyrazinamide). Then following that the continuation phase of 9 weeks of daily treatment of RPT, MOX, and INH[ CITATION CDC224 \l 1033 ].
Diagnostic testing- Chest x-ray, CBC, TB skin test, an Acid-Fast Bacillus (AFB) smear and culture[ CITATION Med212 \l 1033 ].
Education- Patient education on the transmission of TB. Side effects of treatment medication include nausea or vomiting, loss of appetite, a yellow color to your skin (jaundice), dark urine, easy bruising, or bleeding, blurred vision[ CITATION CDC224 \l 1033 ]. Patient educated on the importance of isolating at home for the first two week and wearing a mask when necessary to interact with others. Additional education on the important of compliance of the medication and treatment plan.
Follow-up/Referral- Patient to return in two weeks for a follow up to ensure medication treatment compliance. It is important that patients have clinical evaluations at least monthly to identify possible adverse effects of the anti-TB medications and to assess adherence[ CITATION CDC224 \l 1033 ].
Also necessary is obtaining sputum specimens for microscopic examination and culture. The sputum specimens should be obtained monthly at a minimum until the patient has two consecutive specimens that are negative on culture. It is also important to obtain a sputum specimen at the end of the first two months of treatment, to determine if the continuation phase needs to be longer[ CITATION CDC224 \l 1033 ].
CDC. (2022). Interim Guidance: 4-Month Rifapentine-Moxifloxacin regimen for the treatment of drug- susceptible pulmonary tuberculosis — United States, 2022. Retrieved from CDC: cdc/mmwr/volumes/71/wr/mm7108a1.htm?s_cid=mm7108a1_w
MedlinePlus. (2021). Acid-Fast Bacillus (AFB) Tests. Retrieved from Medline Plus: medlineplus/lab-tests/acid-fast-bacillus-afb-tests/
Week 4 DB NURS 681 copy - Physical Assessment
Course: Advanced Physical Assessment (NURS 681)
University: West Coast University
