Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages to Order 5-10 Pages Description/Paper Instructions
SUBJECTIVE
Antonio is an 84‐year‐old male resident of a continuing care retirement community (CCRC). The residential director admitted him to the respite care wing of the nursing home last evening due to behavior changes including agitation, disorientation, and wandering outside without appro-priate clothing. The director brings him to the on‐site clinic the next morning. She reports that the on‐call provider last evening ordered 1 mg of IM haloperidol, which was given soon after the resident came to the unit. The residential director reports that Antonio had a poor appetite for a few days before this and was found napping in the lounge, which is not unusual. He fell on his way to the dining room the previous morning, but sustained no apparent injury. During his last annual health maintenance visit 3 months prior, he scored 22/30 on the Montreal Cognitive Assessment (MoCA) and was diagnosed with mild cognitive impairment (MCI). He is usually alert and oriented to season, year, place, and person and has no difficulty navigating inside or outside his residence.
His only complaint today is a new complaint of frequent heartburn that he has been treating with over‐the‐counter (OTC) pills (he can’t remember the name). He denies pain, cough, shortness of breath, or changes in bladder/ bowel habits.
Past medical history: Coronary artery disease (CAD) with angioplasty/stent placement ×2, hyper-tension (HTN), benign prostatic hypertrophy (BPH), asthma, hyperlipidemia (HLD), heart failure with normal ejection fraction (HFNEF), mild cognitive impairment (MCI), osteopenia, and osteo-arthritis (OA). He had a motorcycle accident in his youth with a left leg injury.
Psychosocial history: Antonio moved to the CCRC 1 year ago with his wife, who died 4 months prior. He cared for her until she died, then stayed in his apartment, complaining of anxiety and difficulty sleeping. He recently became more involved in community activities and has been making friendships in the building. He has been attending two meals per day in the communal dining room, until this week, and has been independent in bathing, dressing, grooming, walking, transferring, eating, and toileting. He does not climb stairs due to poor endurance but is able to walk on level ground over modest distances without fatigue. Before his wife died, he would take the community van to local shops twice a month. He has a daughter‐in‐law and two nieces who live within 50 miles, call weekly, and visit once or twice a month.
Medications: Fluticasone propionate 100 mcg/salmeterol 50 mcg (Advair Diskus), one inhalation twice per day; simvastatin, 40 mg by mouth, once daily; atenolol, 100 mg by mouth, once daily; losartan, 50 mg by mouth, once daily; furosemide, 20 mg by mouth, once daily; K‐dur, 10 mEq by mouth, once daily; isosorbide mononitrate ER (Imdur), 30 mg by mouth, once daily; alendronate, 70 mg once per week; multivitamin (MVI) with iron, 1 by mouth, once daily; vitamin C, 500 mg by mouth, twice daily; docusate sodium succinate, 1 by mouth, once daily; OTC medication ‐ unknown for heartburn.
Allergies: NKDA.
Health maintenance: Td vaccine 2007. Never had the flu vaccine, pneumococcal vaccine, or shin-gles vaccine (received education/information on last visit).
OBJECTIVE
Vital signs: Temperature: 100.0°F; pulse: 58 (irregular); respirations: 28; blood pressure: 168/58;
weight: 161 (164 last month); height: 72 inches.
Note: His usual vital signs are: Temp: 97.4°F; pulse: 70–80 (regular); BP: 130–140/60–70).
General: Today Antonio appears sleepy, disheveled, restless, and vague. He can walk to the exami-nation room but is unsteady and needs assistance getting undressed for the physical examination. He is unable to fully cooperate with the exam. His skin is dry, especially over the lower extremities.
Mental status: Speech is slow but clear; thought processes are slow and disorganized; irritable mood; distractible; decreased ability to focus. MOCA15/30.
Head: Normocephalic without obvious lesions, masses, depressions, or tenderness. No temporal bruits.
Eyes: Visual acuity 20/40 bilaterally with glasses. Eyelids are symmetrical with no ptosis, but slight ectropion bilaterally. PERRLA. Conjunctiva and sclera clear with slight arcus senilis. EOMs and visual fields WNL with slight decrease in upward gaze bilaterally. He has a few beats of horizontal nystagmus on extreme lateral gaze. Red reflexes intact but incomplete visualization of retinas due to difficulty cooperating with exam and frequent eye closing/sleepiness.
Ears: Unable to cooperate with hearing acuity screen. External ears are without lesions or tender-ness. Canals are obstructed with dark cerumen bilaterally. Unable to visualize TMs.
Nose/sinuses: Nares patent with pink mucosa; no lesions, deviations, or discharge. No frontal or maxillary sinus tenderness.
Mouth/throat: Oral mucosa dry and intact. Tongue and uvula midline, and tongue movement is symmetrical. Pharynx clear. No lesions, masses, cavities, or bleeding.
Neck: Supple; no carotid bruits or thyromegaly. No cervical lymphadenopathy.
Chest: No skin lesions, deformities, tenderness, crepitus, axillary lymphadenopathy, or breast masses. No rubs or thrills. PMI nonpalpable.
Heart: Regular rhythm with frequent pauses. No murmurs or obvious gallops.
Lungs: Symmetrical chest wall expansion. Resonance on percussion throughout all fields. Fremitus palpable and symmetrical. Fine crackles at left base, and coarse inspiratory crackles
and expiratory rhonchi over right lower lung field. No egophony, bronchophony, or whispered pectoriloquy.
Abdomen: Soft, nontender, with quiet bowel sounds in all quadrants; no palpable masses,
organomegaly, or bruits. Soft stool in rectum; hemoccult negative. Slightly enlarged prostate, symmetrical. No palpable masses.
Neurologic: Gait shuffling with small steps. Slightly unsteady, leaning to one side. Unable to stand with feet together without swaying. No pronator drift. No postural or intention tremor. CNs II–XII grossly intact. Reflexes 3+ and symmetrical in both upper extremities. Lower extremities: 2+ patellar reflex, 1+ Achilles reflex. Plantar reflex ↓. Able to detect pain in all extremities, but unable to cooperate with full sensory or coordination testing.
Musculoskeletal: Muscle strength 4/5 in upper and lower extremities bilaterally.
Peripheral vascular: Bounding radial and brachial pulses: 2+. Femoral and popliteal: 2+. Pedal:
1+. Unable to detect posterior tibial pulse. Ankle edema bilaterally with left > right: 2‐3+.
CRITICAL THINKING
Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?
___Head CT or MRI
___Chest X‐ray
___Abdominal X‐ray___Urinalysis
___EKG
___CBC with diff
___Complete metabolic panel (includes: albumin, blood urea nitrogen, calcium, carbon, chloride, creatinine, glucose, potassium, sodium, total bilirubin and protein, and liver enzymes ___Ammonia level
___Arterial blood gas or pulse oximetry
___TSH, free T4, T3
___Toxic screen of blood or urine
___Orthostatic blood pressure
___Depression screening
___Rapid plasma reagin (RPR)
___HIV
___B12/folate
___Lumbar puncture
___Electroencephalogram (EEG)
___Cultures (urine, sputum or blood)
Which differential diagnoses should be considered at this point?
__Dementia
__Depression
__Delirium
__CVA/TIA
__Psychiatric/mental health condition
What is the treatment plan?
Are any referrals needed?
What aspects of the health history require special emphasis in older adults?
What if this patient were under age 65? Would that change the management plan?
What patient, family, and/or caregiver education is important in this case?
Are there any standardized guidelines that should be used to assess or treat this case?
What are some of the possible contributors to this patient’s hypotension? Are any referrals needed? What management strategies should be considered?
RUBRIC
QUALITY OF RESPONSE NO RESPONSE POOR / UNSATISFACTORY SATISFACTORY GOOD EXCELLENT Content (worth a maximum of 50% of the total points) Zero points: Student failed to submit the final paper. 20 points out of 50: The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. 30 points out of 50: The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately. Elements of the required response may also be lacking. 40 points out of 50: The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples. The answer is complete. 50 points: The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples. No aspects of the required answer are missing. Use of Sources (worth a maximum of 20% of the total points). Zero points: Student failed to include citations and/or references. Or the student failed to submit a final paper. 5 out 20 points: Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. 10 out 20 points: References to scholarly sources are occasionally given; many statements seem unsubstantiated. Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. 15 out 20 points: Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented. APA 6th Edition is used with only a few minor errors. There are minor errors in reference and/or citations. And/or there is some use of questionable sources. 20 points: Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented. APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. Grammar (worth maximum of 20% of total points) Zero points: Student failed to submit the final paper. 5 points out of 20: The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors 10 points out 20: The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors 15 points out of 20: The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. 20 points: The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. Structure of the Paper (worth 10% of total points) Zero points: Student failed to submit the final paper. 3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. 5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. They can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements. The student also significantly writes too large or too short of and paper 7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. 10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally, the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper. GET THIS PROJECT NOW BY CLICKING ON THIS LINK TO PLACE THE ORDER
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