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M.F.A Case Presentation Study for Week 7 NR602: Primary Care of the Childbearing and Childrearing Family Chamberlain University Fall 2018 Dwayne V. Ford, RN-BSN WEEK 7: Women’s Health Week 7 SOAP NOTE Patient Information: Name: M.F. Age: 86 years old Gender: Female Ethnicity: Caucasian Insurance: Blue Cross

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by

Liu
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NR 602 WEEK 7

Subjective:

Chief Complaint (CC): M.F. reports, “I had an operation since the last time I was here and now I am having dizziness and diarrhea; plus, you need to check where all my insides were pushed back in—everything was falling out of my vagina.”

History of Present Illness (HPI): M.F. is an 86-year-old female who presents for a follow-up appointment accompanied by her daughter. The daughter explains that the patient underwent a surgical procedure to address prolapse, where both her rectum and uterus were protruding through her vagina. Since the surgery, M.F. has experienced episodes of dizziness, persistent diarrhea, and some episodes of delirium. The patient also complains of sinus headaches and nasal congestion, describing herself as feeling ‘stuffy.’ These symptoms have developed postoperatively, and she is concerned about their ongoing impact on her well-being.

Review of Systems (ROS):

  • Constitutional: Reports dizziness and feeling unwell.
  • HEENT: Complaints of sinus headaches and nasal congestion.
  • Cardiovascular: No chest pain, palpitations, or edema reported.
  • Respiratory: No shortness of breath or cough.
  • Gastrointestinal: Reports diarrhea but denies nausea or vomiting.
  • Genitourinary: Follow-up for postoperative recovery of rectal and uterine prolapse surgery. No dysuria or hematuria reported.
  • Neurological: Episodes of delirium, no focal neurological deficits reported.
  • Musculoskeletal: No joint pain or muscle weakness.
  • Integumentary: No rashes or skin lesions.

Current Medications:

  • Lisinopril 20 mg: For hypertension management.
  • Atorvastatin 40 mg: For cholesterol management.
  • Vitamin D3 2000 IU: For bone health and vitamin D deficiency prevention.
  • Colace 100 mg BID: To prevent constipation, likely related to her recent surgery and current medications.
  • Levothyroxine 88 mcg: For hypothyroidism management.

Allergies: No known drug allergies (NKDA).

Objective:

Vital Signs:

  • Blood Pressure: 130/82 mmHg
  • Heart Rate: 78 bpm
  • Respiratory Rate: 16 breaths per minute
  • Temperature: 98.6°F (oral)
  • SpO2: 97% on room air

Physical Exam:

  • General: The patient appears frail but is alert and oriented to person, place, and time. She exhibits mild distress due to dizziness and gastrointestinal discomfort.
  • HEENT: Mild nasal congestion, sinus tenderness noted upon palpation. No throat erythema or exudate.
  • Cardiovascular: Heart sounds are regular, with no murmurs, gallops, or rubs.
  • Respiratory: Clear to auscultation bilaterally, no wheezing, rales, or rhonchi.
  • Gastrointestinal: Abdomen is soft, non-tender, with normal bowel sounds. The patient reports loose stools without blood or mucus.
  • Genitourinary: External genitalia inspection shows well-healed surgical scars from the recent prolapse repair. No signs of infection or complications are noted. No vaginal discharge.
  • Neurological: The patient shows signs of mild confusion, but no focal neurological deficits are noted. Reflexes are normal.

Assessment:

  1. Postoperative Complications: Likely related to recent rectal and uterine prolapse surgery, contributing to dizziness and diarrhea.
  2. Sinusitis: As evidenced by sinus tenderness and nasal congestion, possibly contributing to the patient’s headaches and ‘stuffy’ feeling.
  3. Delirium: Postoperative in nature, potentially exacerbated by infection, dehydration, or medication effects.
  4. Dehydration: Secondary to diarrhea and insufficient fluid intake, possibly contributing to dizziness.

Plan:

  1. Management of Dizziness and Diarrhea:
    • Review and adjust medications if necessary, particularly those that may cause or exacerbate dizziness or gastrointestinal upset.
    • Recommend hydration with oral rehydration solutions to address possible dehydration.
    • Consider stool studies to rule out infection as a cause of diarrhea.
    • If symptoms persist, further diagnostic testing, including blood work and imaging, may be required.
  2. Follow-Up on Surgical Site:
    • Perform a thorough examination of the surgical site to ensure proper healing and no signs of infection or recurrence of prolapse.
    • Educate the patient on signs of potential complications and when to seek immediate medical attention.
  3. Address Sinus Congestion and Headache:
    • Prescribe a saline nasal spray or decongestant to relieve nasal congestion.
    • Consider an over-the-counter analgesic for headache relief if not contraindicated.
    • If sinusitis is suspected, consider starting an appropriate antibiotic.
  4. Monitor and Manage Delirium:
    • Monitor cognitive status closely, ensuring the patient is reoriented regularly.
    • Assess for potential causes of delirium, including medication side effects, infection, or metabolic imbalances.
  5. Patient Education and Follow-Up:
    • Provide education on the importance of medication adherence, particularly in managing hypertension and hypothyroidism.
    • Schedule a follow-up appointment in 1-2 weeks to reassess symptoms and adjust the treatment plan as necessary.
    • Encourage the patient and family to report any new or worsening symptoms immediately.