Patient Case and Assessment

Patient Case and Assessment

Describe your clinical experience for this week.

• Did you face any challenges, any success? If so, what were they?
• Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.
• Mention the health promotion intervention for this patient.
• What did you learn from this week’s clinical experience that can beneficial for you as an advanced practice nurse?
• Support your plan of care with the current peer-reviewed research guideline.

Submission Instructions:

• Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.

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APA

Answer

Patient Case and Assessment

The patient, a 62-year-old male with a history of hypertension and type 2 diabetes, presented with complaints of shortness of breath, fatigue, and mild chest discomfort. These symptoms had been intermittent over the past week but were exacerbated over the last 24 hours, prompting the patient to seek care. The patient denied any prior history of similar episodes and noted compliance with his prescribed medications. On examination, vital signs revealed elevated blood pressure (BP 160/95 mmHg), a regular heart rate of 98 beats per minute, and mild peripheral edema in the lower extremities. Auscultation revealed diminished breath sounds in the left lower lung field, with no audible crackles or wheezing. Additionally, he reported slight weight gain over the past few days, which he attributed to dietary indulgence.

The assessment was challenging due to overlapping signs and symptoms that could fit various conditions. However, my clinical intuition and experience, paired with diagnostic guidelines, helped me systematically evaluate the possibilities. Patient Case and Assessment

Differential Diagnosis with Rationales

1. Congestive Heart Failure (CHF) – The patient’s history of hypertension, along with recent weight gain, edema, and shortness of breath, pointed toward possible CHF exacerbation. The American Heart Association (2023) guidelines emphasize that heart failure can…