Writing Homework Help

Reply:

Challenges in the Clinical Experience

I will say this week has been just great. I have achieved many new experiences when it comes to the way of approaching patients and their sicknesses. My preceptor has been helpful to all my needs and questions, giving me the answer to those questions that I may have for specific patients, which sometimes can become a challenge at the time of getting the best treatment there for them. Telehealth was another great way of contacting patients, now with the CONID 19, many of the patients mostly elderly adults feel this is one as one of the best ways to see their providers, without having to expose themselves to the virus. I feel this is a great improvement in the medical field for those that sometimes can have the limitation of coming to the office. I did not feel that had any challenges at least for this past week, all was really smooth, and the patient was easy to handle.

The Assessment of the Patient with details of the Signs and Symptoms, Assessment, Plan of Care, and Possible Differential Diagnosis

Chief Complaint: Left knee pain and swelling

HPI: 80-year-old woman presents to the office with pain and swelling in her left knee. The pain began 2 days previously and she says that the knee is now hot, swollen, and painful on movement. She also reports that she feels crepitation when she walks, and her motility is decreased. Pain does not improve with OTC medications, like Aleve.  

In the past, she has had a history of mild osteoarthritis of the hips. She has occasional heartburn and indigestion. She had a health check 6 months previously and was told that everything was fine except for some elevation of her blood pressure which was 172/102 mmHg and her creatinine level, which was around the upper limit of normal. The blood pressure was checked several times over the next 4 weeks and found to be persistently elevated and she was started on treatment with 2.5 mg ben-drofluamethizide. The last blood pressure reading was 138/84 mmHg. There is no relevant family history. She has never smoked, and her alcohol consumption averages four units per week. She takes occasional paracetamol for hip pain.

Remarkable physical examination: Her blood pressure is 142/86mmHg. The temperature is 37.5°C and the pulse is 88/min. There is grade 2 hypertensive retinopathy. There is no other abnormality on cardiovascular or respiratory examination. In the hands, there are Heberden’s nodes over the distal interphalangeal joints.

The left knee is hot and swollen with evidence of effusion in the joint with a positive patellar tap. There is pain on flexion beyond 90 degrees and with hyperextension beyond 10 degrees. The integrity of the lateral and medial collateral ligament is intact. Anterior and posterior cruciate ligament intact. The right knee appears normal.

Previous labs:

• Hemoglobin: 12.1 g/dL
• White cell count: 12.4 x 109/L
• Platelets: 384 x 109/L
• Erythrocyte sedimentation rate (ESR): 48 mm/h
• Sodium: 136 mmol/L
• Potassium: 3.6 mmol/L
• Urea: 7.3 mmol/L
• Creatinine: 116 mmol/L
• Glucose: 10.8 mmol/L

Diagnosis:

Etiological diagnosis:

• M13.10 Monoarthritis, not elsewhere classified, left knee: The clinical picture is one of acute monoarthritis. The patient has a history of some hip pains but this and the Heberden’s nodes are common findings in an 80-year-old woman, related to osteoarthritis. The blood results show a raised white cell count and ESR, a raised blood sugar, and renal function at the upper limit of normal (Bay-Jensen et al., 2017).

Differential Diagnosis:

• M00.9: Pyogenic arthritis, unspecified: represents a direct invasion of joint space by various microorganisms, most commonly bacteria. Viruses, mycobacteria, and fungi may be involved that travel through your bloodstream from another part of your body. Septic arthritis can also occur when a penetrating injury, such as an animal bite or trauma, delivers germs directly into the joint (Spinicci & Corti, 2020). Septic arthritis is also becoming increasingly common among persons older than 65 years, among immunosuppressed individuals, and among persons with various comorbidities.
• M10.9 Gout, Unspecified: A form of arthritis characterized by severe pain, redness, and tenderness in joints severe pain, redness, and swelling in joints, often the big toe. Attacks can come suddenly, often at night (Zhang & Taylor, 2020).
• M06.9 Rheumatoid arthritis (RA), unspecified: A chronic inflammatory disorder affecting many joints, including those in the hands and feet. Joint pain, tenderness, swelling, or stiffness that lasts for six weeks or longer. Morning stiffness that lasts for 30 minutes or longer. More than one joint is affected. Small joints (wrists, certain joints in the hands and feet) are typically affected first. The same joints on both sides of the body are affected. Patients with RA get very tired (fatigue) and some may have a low-grade fever (Kim & Go, 2020). RA symptoms may come and go. Having a lot of inflammation and other symptoms are called a flare. A flare can last for days or months.

Plan:

• X-ray of the left knee.
• Left knee MRI

A follow-up appointment was set up after MRI and x-ray have done.

The recent introduction of a thiazide diuretic for the treatment of hypertension increases the suspicion of gout. Gout is caused by the deposition of uric acid crystallizes and would be expected to show calcification in the articular cartilage in the knee joint. The X-rays here show some joint space narrowing but no calcification in the articular cartilage. The fever, high white cell count, and ESR are compatible with acute gout (Krasnokutsky et al., 2017). The raised glucose may also be a side effect of thiazide diuretics. If this remains after acute arthritis has subsided, then it may need further treatment. Precipitation of gout by thiazides is more likely in older women, particularly in the presence of renal impairment and diabetes. It may involve the hands, be polyarticular, and can affect existing Heberden’s nodes (Zhang & Taylor, 2020).

The serum uric acid level is likely to be raised, but this occurs commonly without evidence of acute gout. The definitive investigation is the aspiration of the joint. The fluid should be sent for culture and inspection for crystals. A high white cell count would be expected in acute inflammatory arthritis. The diagnosis is made from the needle-like crystals of uric acid which are negatively birefringent under polarized light, unlike the positively birefringent crystals of calcium pyrophosphate (Kim & Go, 2020).

In this case, the pain in the joint was partly relieved by the aspiration. Treatment with a non-steroidal anti-inflammatory drug should be covered by a proton pump inhibitor in view of her history of heartburn and indigestion. The thiazide diuretic was changed to an angiotensin-converting enzyme inhibitor as treatment for her hypertension, and the blood glucose settled.

Lesson Learnt

From my week’s experience, I completely understand the importance of cultural awareness. Cultural awareness is critical in giving full patient-based care. Different cultural values and beliefs affect patients’ perceptions of care, health, wellness, treatment acceptance, and adherence (Salmond et al., 2017). Comprehending, accommodating, and respecting patients’ preferences and desires regarding the practices, beliefs, and customs should be included in the planning and delivery of care no matter the patient’s age. Acknowledging own biases helps in understanding culturally competent care hence more information on awareness in the nurse practicing. Therefore, the most we can know about patient cultural preference, the most we can have them follow and complete the expected protocol of their diagnosis.

                                                                                              References

Bay-Jensen, A., Abramson, S., Samuels, J., Byrjalsen, I., Krasnokutsky Samuels, S., Manon-Jensen, T., Asser Karsdal, M., & Attur, M. (2017). Knee osteoarthritis pain is differentially associated with tissue degradation and joint inflammation. Osteoarthritis and Cartilage, 25, S353.

https://doi.org/10.1016/j.joca.2017.02.599

Beigzadeh, A., Bahaadinbeigy, K., Adibi, P., & Yamani, N. (2019). Identifying the challenges to good clinical rounds: A focus-group study of medical teachers. Journal of Advances in Medical Education & Professionalism, 7(2), 62.

Kim, H., & Go, D. (2020). Lack of association between serum urate levels and osteoarthritis progression in non-gout subjects. Osteoarthritis and Cartilage, 28, S40-S41.

https://doi.org/10.1016/j.joca.2020.02.066

Krasnokutsky, S., Oshinsky, C., Attur, M., Ma, S., Zhou, H., Zheng, F., Chen, M., Patel, J., Samuels, J., Pike, V. C., Regatte, R., Bencardino, J., Rybak, L., Abramson, S., & Pillinger, M. H. (2017). Serum urate levels predict joint space narrowing in non?gout patients with medial knee osteoarthritis. Arthritis & Rheumatology, 69(6), 1213-1220.

https://doi.org/10.1002/art.40069

Salmond, S. W., Cadmus, E., Black, K. K., Bohnarczyk, N., & Hassler, L. (2017). Long-term care nurse residency program: Evaluation of new nurse experiences and lessons learned. The Journal of Continuing Education in Nursing, 48(10), 474-484.

Spinicci, M., & Corti, G. (2020). Septic arthritis in the antimicrobial stewardship era. Internal and Emergency Medicine, 15(4), 567-569.

https://doi.org/10.1007/s11739-020-02302-6

Zhang, W., & Taylor, W. J. (2020). Outcome measures in gout. Arthritis Care & Research, 72(S10), 72-81.

https://doi.org/10.1002/acr.24209