Ariela Hernandez is a 64-year-old obese female with hypertension. She has been a current smoker for the past 40 years, has diabetes, and had a right knee replacement six weeks ago. Mrs. Hernandez complained of acute onset of dyspnea and near syncope, and associated symptoms are shortness of breath, cough, right calf tender, and swelling. After physical examination, one revealed possible signs of pulmonary embolism.
In the current case, based on the history, the survey, and the problem list, the following tests and analyzes should be ordered. Firstly, one needs to check the basic indicators of the body. To do this, Ms. Hernandez should pass a full blood panel, an electrocardiogram of the heart, and an ultrasound of the lungs and abdomen. It is necessary to palpate the abdomen to check for the presence of tumors or neoplasms. One also should carefully examine the scar after knee surgery to check for infection and degree of healing. Furthermore, one has to check the level of sugar in the blood for the presence of a critical deviation from the norm. Next, it is necessary to measure blood pressure, taking into account hypertension, and in case of critical indicators, take appropriate medications to relieve the hypertensive crisis.
Nowadays, there are many knee replacement surgery occurring, however, it is still a complex procedure. It is a surgical process to replace the surfaces of the knee joint to relieve pain and disability (Malhotra & Gautam, 2019). The recovery period usually is for three weeks, although tenderness and swelling may be followed by up to 3 months. Moreover, it can take a year for swelling to disappear entirely in some cases. Considering the period after the surgery of Ariela Hernandez, namely six weeks, one may conclude that the right calf tender and swollen is standard. However, one needs to examine the surgery area in detail to ensure there is no infection and that the pace of scar healing is normal. It is also necessary to ask the patient to inform about any bad feelings in the calf if such will appear.
Evaluation of the test results to determine the actual and/or potential diseases for which Ariela Hernandez (AH) is at risk showed the following results. Given hypertension and long-term smoking, one of the dangers for Ariel Hernandez is a hypertensive crisis. A hypertensive crisis is a severe increase in blood pressure, which potentially may lead to a stroke (Chopra, 2021). Such a condition is usually accompanied by pre-syncope and shortness of breath. Based on this, considering the patient’s main complaints, one may conclude that the hypertensive crisis has already taken place. Blood pressure-lowering medications are used to treat hypertensive crises (Chopra, 2021). To do this, one may also use diuretics to reduce swelling of the brain and blood vessels.
Further, evaluation of the test results showed actual diseases of the patient. The patient has swelling of the right calf caused by surgery. Further, immediate medical intervention might be required if a possible pulmonary embolism is diagnosed. A pulmonary embolism is a blockage of one of the lungs’ blood vessels by a clot, which leads to a violation of blood circulation in the lungs (Lebron & Heresi, 2020). It is followed by a decrease in the level of oxygen in the blood and may also lead to a deterioration in blood flow throughout the body and create an excessive load on the heart. Given the overweight of the patient, this poses a severe threat, on the basis of which one has several treatment options.
Pulmonary embolism can be treated both inpatient (1-3 days) and outpatient, that is, the patient does not need to stay in the hospital overnight. It depends on many factors, including the degree of shock, the size of the clot, and the level of oxygen in the blood. In the case of a normal condition, it is necessary to prescribe an injection of a thrombolytic drug to break up blood clots (Lebron & Heresi, 2020). With a sharp decrease in oxygen in the blood or blood flow, shock treatment is necessary, which includes resuscitation. In some cases, surgery may be needed to remove the clot. Given Ms. Hernandez’s condition, it is essential to check the oxygen level in the blood and take an x-ray of the lungs to identify or rule out a pulmonary embolism.
A summary note explaining how one should arrive at Ariela Hernandez’s problem list would involve the following points. The best way to create and deal with the patient’s problem list is a SOAP model (Gateley & Borcherding, 2017). The subjective data as reported by the patient is documented (the ‘S’), followed by measurable objective data (O), then any clinical assessment data (A), and finally, the clinical plan (P) (Gateley & Borcherding, 2017). Thereby, a clinical plan would be formulated by further actions related to the patient.
Relevant assessment results involve questions, which one asks a patient to have a full database. Thus, the questions would be of the following nature: firstly, it is necessary to ask about the name, age, residence, family, significant partner, religion, workplace, and lifestyle. Further, one needs to complete the clinical picture and to ask about any other symptoms, diseases of family members, hospitalizations, any drugs used, any current or past medical problems. It is also necessary to find out if the patient has asthma or if one takes any prescription, herbal medications, or any other. One should be aware if the patient takes insulin for diabetes. Finally, one needs to know about the amount of alcohol drinking and whether the case smokes cigarettes and drinks caffeine beverages. Answers are formulated by the abovementioned patients’ complaints and information.
The lab results that correlate with the assessment findings are formulated by tests and examinations which are necessary for the patient. These include a full blood panel to be aware of the general condition and the level of red and white cells. It is also necessary to define the level of oxygen in the blood since there is a threat of severe pulmonary embolism. Besides, the lab results would also involve an x-ray of the lungs to find out if there is a clot. Thereby, by these tests, one would be able to find out if the patient has a pulmonary embolism and needs hospitalization.
The summary, evidence-based assessment guidance, and interview results documentation include a clinical plan developed on the basis of all the abovementioned data. Thus, it is necessary to continue physical therapy, which would involve medication taking and examination conducting. Furthermore, the patient should continue diabetes treatment and sugar level in blood monitoring. It is crucial to stress the importance of walking for the patient every two hours throughout waking periods. Similarly, the patient has to be stressed about the significance of smoking cessation.
References
Chopra, H. K. (2021). Hypertension: New frontiers: A textbook of cardiology. Jaypee Brothers Medical Publishers.
Gateley, C. A., & Borcherding, S. (2017). Documentation manual for occupational therapy: Writing soap notes. (4th ed.). Slack Incorporated.
Lebron, B. R., & Heresi, G. A. (Eds.). (2020). Pulmonary embolism: From acute PE to chronic complications. Springer Nature.
Malhotra, R., & Gautam, D. (2019). Mastering orthopedic techniques: Revision knee arthroplasty. Jaypee Brothers Medical Publishers.