Interdisciplinary Care Assessment: Right Shoulder Pain - Essay Example

"Interdisciplinary Care Assessment: Right Shoulder Pain" is a wonderful example of a paper on care.
Subjective data: A 66-year-old male patient with a previous medical history of alcohol abuse from the time he was 25 years and a history of hypertension, brought in by the paramedics. Patient reports that he was walking home before he fell and got picked up. Other than reporting that he fell on his shoulder, the patient cannot recall anything else. Although the patient denies loss of consciousness, he is unable to remember the incident. While being examined, the patient stated that he felt pain at his shoulder.

Objective data: The patient’s blood pressure measured 206/120 at the time of arrival at the hospital. CT scan of the head revealed small vessel ischemic variations, several lacunar infarcts, and atrophy. CT scan of the spine did not show any sign of fracture. Further assessment showed that the patient’s response was slow. Although the patient knew that he was in the hospital, he was unable to recall the date.

Relevant medical and surgical history

The patient has reported hypertension in the past, but no documented drug for controlling hypertension.

The patient has had surgery of the ankle in the past.

Admitting diagnosis

Right shoulder pain

 History of present illness

The patient is a 65-year-old male with previous hypertension and alcohol abuse who presents today with a sudden fall that was followed with the loss of consciousness. The patient has also had a previous history of ankle surgery. His current complaint is that of pain around the area of his left. However, the patient does not complain of any headache and denies lack of consciousness when he cannot remember the events that occurred during the time that he fell down. The patient also denies tingling, paralysis on any of his body sides, or paresthesias. CT scan of the head revealed atrophy and minor vessel ischemic variations and several lacunar infarcts. X-ray analysis shows that his left shoulder does not have any dislocation or fracture but instead a slight degeneration and fraying if glenoid labrum. The patient has had to follow up with an orthopedic doctor on his recurrent falls. He has also had to see a neurologist regarding his confusion, loss of memory, mental status, disruption in motion, and slow response. Further, follow up with a psychiatrist has been required of the patient to show reasons for behavioural problems. The patients have further had to check with nephrologist regarding his renal function as necessitated by his abnormal BUN and Creatinine levels of 42 and 2.3 respectively.

Review of Systems (ROS)

• Constitutional: no pertinent history
• Eyes: vision is perfectly normal, and there is no reported symptom.
• Ears/Nose/Throat: hearing is normal.
• Mouth: speech appears to be quite slow.
• Cardiovascular: the patient has had a previous history of syncope and hypertension.
• Respiratory: No reported symptoms
• Gastrointestinal: No reported gastrointestinal problems
• Genito-Urinary: No reported genitourinary related symptoms
• Male reproductive: No reported symptoms
• Female Reproductive: Not applicable
• Musculoskeletal: Pain on the left-hand side of the shoulder caused by moderate degeneration and the wearing of the glenoid labrum
• Neurological: patient appears to have slight memory loss
• Skin: No reported symptoms.
• Endocrine: No reported symptom
• Hematologic/Lymphatic: No reported symptoms.
• Psychiatric: Depression attributed to fall and hospitalization, no other symptom.

Lab tests

Date

Lab Test

Results

Norms

Comments

5/18/2014

Hemoglobin

13.3

12-16.5

Within normal range

Hematocrit

39.4

36-46

Within normal range

Platelet count

421

140-440

Within normal range

MCV

89.3

81-95

Within normal range

MCH

30.4

28-32

Within normal range

RDW

13.5

11.5-14.5

Within normal range

Sodium

133

132-143

With normal range

Potassium plasma

4,4

3.5- 5.5

With normal range

creatinine

2.3

0,6-1.3

Above normal range

Blood urea nitrogen

42

6-22

Above normal range

Albumin

4.1

3.2-4.9

Within normal range

Triponin

0.02

The lab results depict creatinine and blood urea nitrogen as above normal range. The kidneys usually sustain the blood creatinine within acceptable ranges. It is a reliable pointer of kidney function and, therefore, the high levels imply kidney failure or disease. Since the patient has high blood pressure, it is clear that it is the main cause of kidney failure or disease (end-stage renal disease). Hypertension usually causes damage to the filters and vessels of the kidney, making exclusion of waste from one’s body hard. The patient may require a blood cleansing procedure (Ulrich, 1991). Poor functioning of the kidneys consequently leads to high levels of blood urea nitrogen, which are above normal ranges as depicted by the lab results.

Medication

• Benazepril (Lotensin) 10 mg daily dose: this medication is an Angiotensin Converting Enzyme that ought to be given as a fist line pharmacologic mediation.

Side effects and patient education

Benazepril may lead to severe stomachache, hives, difficulty breathing, swelling of lips, throat, or tongue. The patient should call the doctor in case they:

• Feel lightheaded
• Urinate excessively
• Have a fever, body aches, chills, and flu-like symptoms
• Experience bleeding, pale skin, or easy bruising

• Amlodipine 10mg (Norvasc): this is a calcium channel blockers added to the ACE to achieve the blood pressure goal.

Side effects and patient education

The patient should monitor for weight gain and swelling of the face.

The patient should call the doctor in case they experience excessive swelling of the face and legs, irregular heartbeat, constipation, or dizziness. 

Combination of ARB, ACEi, and calcium channel blockers prove efficient in lowering blood pressure and countering creatinine and blood urine nitrogen (Toto, 2005).

Interventions

Engage patient in routine exercise to reduce the risk of heart attack or stroke and reduce hypertension. Continue with monitoring of blood pressure levels and the levels of creatinine and blood urea nitrogen

Interdisciplinary care

Collaborative Management

Physician: assessment of patient condition and provision of prescription

Diagnostic personnel: conduct blood tests

Physical therapists: engage patient in exercise

Pastoral care: help patient gain confidence, self-esteem, and faith in medical interventions

Nursing Role Reflection