Patient Assessment

Describe your clinical experience for this week.

  • Did you face any challenges, any success? If so, what were they?
  • Describe the assessment of a patient detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.
  • Mention the health promotion intervention for this patient.
  • What did you learn from this week’s clinical experience that can beneficial for you as an advanced practice nurse?
  • Support your plan of care with the current peer-reviewed research guideline.

Submission Instructions:

  • Post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

Patient Assessment

Patient Assessment:

Mr. S, a 58-year-old male, presented to the clinic with a complaint of fatigue, fever, and muscle aches for the past 5 days. He reported a loss of appetite and had been experiencing night sweats. Mr. S has a history of hypertension and is currently on medication for it. He denies any recent travel or sick contacts.

Signs and symptoms:

  • Fatigue
  • Fever
  • Muscle aches
  • Loss of appetite
  • Night sweats

Assessment: Upon examination, Mr. S had a temperature of 101.5°F, and his blood pressure was 138/86 mmHg. His lungs were clear, and his heart sounds were regular without murmurs. His abdomen was soft and non-tender, and no lymph nodes were palpable. He had no rashes or lesions on his skin.

Plan of Care: Based on Mr. S’s clinical presentation, three differential diagnoses that must be considered are:

  1. Influenza: Given the current flu season, influenza is a possible diagnosis. The flu can cause fever, muscle aches, fatigue, and loss of appetite.
  2. COVID-19: COVID-19 is a viral illness that can present with fever, fatigue, muscle aches, and loss of appetite. Night sweats are not a typical symptom, but they have been reported in some cases.
  3. Endocarditis: Endocarditis is an infection of the heart’s inner lining and valves. Symptoms include fever, fatigue, muscle aches, and loss of appetite. Patients with hypertension are at an increased risk of developing endocarditis.

To confirm the diagnosis, Mr. S will undergo a series of diagnostic tests, including a complete blood count (CBC), influenza and COVID-19 testing, and a blood culture to rule out endocarditis. Supportive care includes rest, hydration, and over-the-counter pain relief.

Health Promotion Intervention: As an advanced practice nurse, I would recommend that Mr. S receives the annual flu vaccine to prevent future flu infections. Additionally, I would educate him on the importance of hand hygiene, especially during flu season, to reduce the spread of illness.

Conclusion: In conclusion, assessing and diagnosing patients with febrile illnesses requires a thorough evaluation of their symptoms and risk factors. The differential diagnoses must be considered based on the clinical presentation and confirmed through appropriate diagnostic testing. Providing appropriate supportive care and promoting healthy habits, such as hand hygiene and vaccination, can help prevent future illnesses. As an advanced practice nurse, I would stay current with evidence-based research to provide the best possible care to my patients.

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