COMPLETE LOG (COMPREHENSIVE) ADULT – COMPLETE H & P COMPLETE HISTORY………………………………………………………………………… 30% (refer to notes from class 1 for what is in each category below): Date Identifying data Reliability...

Running Head: A Case Study 2
A Case Study
Contents
COMPLETE HISTORY    1
Date    1
Identifying data    1
Reliability    1
Chief Complaint    1
History of Present Illness    1
Past Medical History    2
Past Surgical History    2
Personal and Social History    2
Family History    3
REVIEW OF SYSTEM    3
PHYSICAL EXAMINATION    4
ASSESSMENT/PROBLEM List    4
ASSESSMENT    4
MAIN DIAGNOSIS AND DIFFERENTIAL DIAGNOSES    5
Main Diagnosis    5
Differential Diagnoses    5
OTHER PERTINENT AND POTENTIAL PROBLEM    6
PLAN    7
DIAGNOSTIC    7
THERAPEUTIC    7
FOLLOW-UP    8
REFERRAL    9
PATIENT EDUCATION    9
References    10
COMPLETE HISTORY
Date- XYZ
Identifying data
Mrs. SN is a 47-year-old female.
Reliability
This is a case study of a female who presented with hypokalemia. Her clinical history, assessment, and care plan are discussed in this paper.
Chief Complaint
Hypokalemia
History of Present Illness
Mrs. SN is presented to the MD office with the complaint of hypokalemia. She has been suffering from weakness and muscle cramps for 20 days. She is also experiencing muscle twitching. She has been thirsty again and again and has a frequent urge to urinate. She is usually constipated and suffers from bloating. This is usually associated with vomiting and nausea. She has not shown any link with food and drink. She doesn't have any other symptoms like fever or eyesight loss.
Past Medical History
She has been suffering from type 2 diabetes for 4 years. She is managing type 2 diabetes with metformin. It is still present.
She has been suffering from hyperlipidemia for 3 years. She is managing this condition with a healthy diet. This condition is persisting.
She has been suffering from high blood pressure for 5 years. She is managing her hypertension with monopril. She is still suffering from hypertension sometimes.
Past Surgical History
She has not undergone any kind of surgical procedure in the past.
Medications (Name, drug class, route, frequency, indication)
Metformin for type 2 diabetes. It belongs to the Biguanides. Metformin is taken by oral route. It is taken twice a day after food. It is indicated by high blood sugar levels.
Monopril for hypertension. It belongs to the angiotensin-converting enzyme inhibitor class. Monopril is taken by oral route. It is taken once a day. It is indicated for high blood pressure (Akehi et al., 2019).
Personal and Social History
Since the age of 18, she has smoked approximately 15 cigarettes every day. She has been consuming minimal alcohol lately since it makes her stomach upset. On the other hand, she used to drink a bottle of red wine on weekends. She is married and shares a home with her partner. She has one unmarried daughter who functions full-time as an assistant. She is a housewife who also looks after your two young nephews and nieces three days per week. She visited other countries ten months ago, but she hasn't been internationally since then. She does not exercise regularly.
Family History
Her father had died due to diabetic neuropathy and Alzheimer's disease. Her mother is suffering from hypertension.
REVIEW OF SYSTEM
General: Has gained around 9 pounds in the last four years, with exhaustion.
Skin: No allergies or other abnormalities to the skin.
Head: No ailment.
Eyes: She has been using reading glasses for six years and had them tested 1 year ago. There is no blurry vision or impaired vision.
Ears: Good hearing. There is no ringing, vertigo, or infections.
Nose: No present complaints.
Mouth and Throat: Excessive thirst. No other known complaints.
Neck: No tumors, goitre, or pain in the neck
Breast: No lumps, discomfort, or discharge in the breasts.
Respiratory: No congestion, coughing, difficulty breathing, bronchitis, or infection in the lungs.
Cardiac: There is no heart problem. There was no chest pain, no orthopnea, and no palpitations.
Gastrointestinal: Bloated abdomen. Constipation, nausea, and vomiting are present.
Urinary: There is a frequent urge to urinate. No pain and jaundice.
Genito-Reproductive: Menstrual cycle is regular. There is no vaginal itching or discharge.
Musculoskeletal: Muscle cramps and muscle twitching are present. No joint pain.
Peripheral Vascular: Hypertension.
Neurological: Good memory. No other complaints.
Psychiatric: No nervousness and anxiety.
Hematologic: No anemia
Endocrine: Type 2 diabetes
PHYSICAL EXAMINATION
ASSESSMENT/PROBLEM List
Hypokalemia
Hyperlipidemia
Hypertension
Type 2 diabetes
Weakness
Muscle cramps
Muscle twitching
Excessive thirst
Bloating
Nausea and vomiting
Constipation
ASSESSMENT
Weigh Mrs. SN every day and compare it to the intake and outflow during the next 24 hours. Although increased fluid consumption and weight gain over output cannot precisely indicate intravascular volume, such parameters are relevant for reference. Keep an eye on her vital signs and central venous pressure. Watch for rising temperatures and orthostatic hypotension (Burnier, 2018). CVP measures can assist in determining the severity of an electrolyte imbalance. Keep an eye on her urine output. The demand for fluid replacement is determined by present deficits and continuous losses. Examine skin colour, warmth, and capillary refill while palpating peripheral pulses. Extracellular fluid deficiency can lead to insufficient organ perfusion in each area, which can lead to circulatory collapse or shock (Burrello et al., 2020).
Watch for an abrupt or significant increase in blood pressure. The cardiopulmonary system may be harmed if a fluid deficiency is restored too quickly, specifically if colloids are utilised in overall fluid replacement. Assess Mrs. SN's competency to manage her hydration. Clients' capacity to replace fluids is affected by a variety of circumstances, including nausea. Hypertension and edoema in the setting of renal illness are common physical exam observations. Hypoperfusion symptoms may also be seen. She may experience muscle discomfort. Muscle weakness is common in some individuals (CS & TC, 2020).
MAIN DIAGNOSIS AND DIFFERENTIAL DIAGNOSES
Main Diagnosis
During standard serum electrolyte analysis, hypokalemia [3.5 mmol/L] can be detected. Individuals with typical ECG variations, muscular complaints, or risk factors must be detected and diagnosed by blood testing. An ECG must be performed when a client has hypokalemia. Hypokalemia has limited cardiac consequences until serum potassium values reach 3 mEq/L (Desai et al., 2018)....