Focus Note Template-Advanced Practice Care of Adults Essay

Focus Note Template-Advanced Practice Care of Adults Essay

Subjective Data

Chief Complaint: Pain on the left heel for one month

History of the Presenting Illness

FT is a 44-year-old Caucasian female presenting with left heel pain for one month. She describes the pain as throbbing, She reports that the pain is worse when she first gets up and steps out of bed and she rates the pain 9/10.  The pain reduces to 5/10 after being on her feet for 15 minutes and remains 3-4/10 throughout the day. She takes ibuprofen 600 mg daily with some relief MR. She denies trauma or injury. No new shoes or heels. Works as a lunch lady in the cafeteria at a high school and thinks the pain is from being on her feet a lot. Repots pain only when walking. No pain at rest. Focus Note Template-Advanced Practice Care of Adults Essay

Current Medications: Ibuprofen 600 mg daily for pain for one month, Multivitamin 1 tablet daily.

Allergies: No known drug or food allergies

PMH: Tdap in 2017. No major illnesses or surgeries.

Social History: She works as a lunch lady in the cafeteria at a high school. She has never smoked and does not take alcohol. She lives with her husband and children. She feels safe when at home. She denies domestic violence. She reports that she uses seatbelts all the time. She does not text and drives. She does not have any risky hobbies.

  ORDER  HERE A PLAGIARISM-FREE PAPER NOW

Family History: Daughter aged 15 with type 1 diabetes, diagnosed at age 11. Son age 13 in good health. Mother deceased at age 70 with bladder cancer. Father deceased: diabetes, high cholesterol, MIX2, first MI at age 65. All grandparents deceased in their 80’s unknown illnesses and medical history. 2 brothers in good health. 1 brother with diabetes and high cholesterol.

ROS:

General: Appears well. Denies fatigue, malaise, fever, chills, night sweats, weakness, and unexplained weight loss.

HEENT: Eyes: Denies vision changes such as sudden vision loss. Clear sclera. Wears glasses. Ears, Nose, Throat denies hearing loss, pain or drainage, no nasal congestion, runny nose, or sneezing. No sore throat.

Skin: warm, dry. No rash or dryness or itching.

Cardiovascular: Denies chest pain/ chest pressure or any chest discomfort. No irregular heartbeat.no palpitations or lower extremity edema.

Respiratory: Negative for cough, sputum, hemoptysis, wheezing, or SOB.

Gastrointestinal: Negative for poor appetite, dysphagia, nausea, heartburn, or reflux, dyspepsia, abdominal pain, excessive gas or bloating, constipation, diarrhea, dark or bloody stools. Genitourinary: No dysuria, pelvic pain, hot flashes, or abnormal bleeding. LMP 08/30/2021.

Neurological: Negative for dizziness, headache, syncope spells, confusion, weakness, numbness, tingling, slurred speech, gait or balance problems, falls, or tremors.

Musculoskeletal: Negative for arthritis, muscle weakness, stiffness. No swollen or painful joints and no night cramps.

Hematologic: No easy bruising, abnormal bleeding, or anemia.

Lymphatics: Negative for enlarged or painful lymph nodes.

Psychiatric: Negative for sleep, disturbance, anxiety, depression, suicidal thoughts.

Endocrinologic: Denies Temperature intolerance, denies symptoms of diabetes: polyuria, polydipsia.

Objective Data

Physical exam

Vital Signs: 98.0 89 20 131/73 O2sat 100% Weight 159 Lbs.

General examination: the patient is well nourished, oriented to time place, and person. She has no pallor, jaundice, cyanosis, edema, dehydration, and lymphadenopathy.

Musculoskeletal Examination: the patient has pain at the plantar medial tubercle. The ankle dorsiflexion is intact. There is no swelling of the joints, there is no erythema, and there is no increased local temperature.

HEENT: The head is normal and a-traumatic. There are no visible scars and masses. There is no facial droop. Her eyes are normal with pupils bilaterally reacting to light with pink conjunctiva. The ears are normal with no obvious discharge or polyps. The nose has a normal external appearance, with pink nasal mucosa and clear drainage. The throat appears to be clear, with no swellings, or ulcerations

Skin: The skin is normal in color, texture, moisture, temperature, mobility, and turgor. There are no abnormal lesions. The hair is in a normal distribution with a normal texture.

RESP: There is symmetrical chest expansion during inspiration. The patient is not in respiratory distress. There are no scars and masses on the chest wall. There is a resonant percussion note. The lung fields are clear with vesicular breath sounds. There is no wheeze or crackles. Focus Note Template-Advanced Practice Care of Adults Essay

GI: The abdomen has a normal contour, moves with respiration, and does not have scars. There is a tympanic percussion note. The bowel sounds are present. There is no shifting dullness and fluid thrills.

GU: the genitalia is without erythema, lesions, or masses. The urethral meatus is without prolapse and the urethra is without scarring. There is no bladder tenderness; there is no dullness to percussion at the region above the symphysis pubis.

Neurologic: Cranial Nerves are intact. The deep tendon reflexes of the upper and lower extremities are symmetrical. The cerebellar function is normal; Romberg’s test is negative. The gait is normal. Sensory testing for pain (pinprick), light touch, position, and vibration is intact.

Psychiatric: The patient is well-oriented to time, place, and person. The patient’s mood is neutral and has a flat affect. The speech rate and quantity are normal with a well-modulated volume. The patient is articulate, coherent; and spontaneous. The flow of words is consistent with normal fluent speech. The patient’s thought processes are logical, relevant, organized, and coherent. The patient’s associations are intact. There are no obsessive, compulsive, phobic, delusional thoughts. There are no illusions or hallucinations. The patient’s judgment concerning everyday activities and social situations is good and insight into their condition is appropriate.

Diagnostic Results:

Erythrocyte sedimentation rate, complete blood count, and rapid plasma regain help rule out autoimmune and infectious causes of joint pain. A plain radiograph reveals a plantar heel spur. It may also help to rule out an old fracture and osteoarthritis. Ultrasonography helps in making a diagnosis of plantar fasciitis through the thickening fascia and the surrounding edema.

Assessment

Differential Diagnoses:

Plantar Fasciitis

Plantar fasciitis is the pain caused by degenerative irritation at the insertion of the plantar fascia in the medial process of the calcaneal tuberosity. The pain is so severe that there is an alteration in the daily activities. The presenting signs and symptoms of plantar fasciitis are heel pain at the anterior aspect of the calcaneus (Trojian, et al, 2019). The pain is severe after a prolonged period of inactivity and vigorous activity, reduced on walking, and is associated with paresthesia. Focus Note Template-Advanced Practice Care of Adults Essay

  ORDER  HERE A PLAGIARISM-FREE PAPER NOW

Gout

Gout is a complex form of arthritis caused by the accumulation of calcium pyrophosphate (Singh, et al, 2020). It presents with joint pain, signs of inflammation on the affected joint (swelling, warmth, erythema, and tenderness). Podagra is the initial joint manifestation

Old fracture

An old fracture is the discontinuation of a bone for more than three weeks and complications caused by delayed treatment or therapy; delayed union, malunion, and non-union of the fractures (Axelsson, et al, 2017). The patient with an old fracture presents with pain, swelling, and tenderness. The pain increases and worsens over time.

.Plan

Pharmacological

Triamcinolone injection 40mg intra-articular stat dose and aceclofenac 100mg PO once a day is the treatment of choice for plantar fasciitis (Trojian, et al, 2019). Bed rest, meloxicam 15mg once a day, and fracture correction in the treatment mode for old fractures. Allopurinol 100mg once a day and meloxicam 15mg once a day is the treatment mode for gout.

Non-pharmacological

Rest activity modification, replacing worn-out shoes, use of motion control shoes, avoid running barefoot, and select shoes with greater cushioning (Trojian, et al, 2019). Refer the patient to a physiotherapist to maintain the function. An occupational therapist will help adjust the shoe heel for this patient. Focus Note Template-Advanced Practice Care of Adults Essay

Reflection note

Plantar fasciitis is a self-limiting condition that has reported 90% resolution. The causes of pain and discomfort are due to the disease process. I would create public awareness on the effects of wearing worn-out shoes and staying barefoot. Public awareness would include campaigning for the use of comfortable shoes with a reasonable size heel. This would help prevent the incidences of plantar fasciitis.

References

Axelsson, K. F., Wallander, M., Johansson, H., Lundh, D., & Lorentzon, M. (2017). Hip fracture risk and safety with alendronate treatment in the oldest‐old. Journal of internal medicine, 282(6), 546-559.

Singh, J. A., & Gaffo, A. (2020, June). Gout epidemiology and comorbidities. In Seminars in arthritis and rheumatism (Vol. 50, No. 3, pp. S11-S16). WB Saunders.

Trojian, T., & Tucker, A. K. (2019). Plantar fasciitis. American family physician, 99(12), 744-750. Focus Note Template-Advanced Practice Care of Adults Essay