NR601 Week_5 Case Study Paper

NR601 Week_5 Case Study Paper


NR601 Week_5 Case Study Paper: The assignment is a paper which is to be written in APA format. This includes a title page and reference page. Review the attached patient visit information. The patient has presented for an acute care visit. You are provided with the subjective and objective exam findings. As the provider, you are to diagnose and develop the management plan for this case study patient. Use the categories below to create section headings for your paper. Introduction: briefly discuss the purpose of this paper. Assessment: review the provided case study information. Identify the primary, secondary and differential diagnoses for the patient. Use the 601 SOAP note format as a guide to develop your diagnoses. Each diagnosis will include the following information:

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1. ICD 10 code. 2. A brief pathophysiology statement which his no longer that 2 sentences, paraphrased and includes common signs and symptoms of the diagnosis. 3. The patient’s pertinent positive and negative findings, including a brief 1-2 sentence statement which links the subjective and objective findings (including lab data and interpretation). 4. A rationale statement which summarizes why the diagnosis was chosen. 5. Do not include quotes, paraphrase all scholarly information and provide an intext citation to your scholarly reference. Use the Reference Guidelines document for information on scholarly references. Plan (there are five (5) sections to the management plan)

1. Diagnostics. List all labs and diagnostic test you would like to order. Each test includes a rationale statement which includes the diagnosis for the test, the purpose of the test and how the test results will contribute to your management plan. Each rationale statement is cited. 2. Medications: Each medication is listed in prescription format. Each prescribed and OTC medication is linked to a specific diagnosis and includes a paraphrased EBP rationale for prescribing. 3. Education: section includes detailed education on all five (5) subcategories: diagnosis, each medication purpose and side effects, diet, personalized exercise recommendations and warning sign for diagnosis and medications if applicable. All education steps are linked to a diagnosis, paraphrased, and include a paraphrased EBP rationale. Review the NR601 SOAP note guideline for more detailed information. 4. Referrals: any recommended referrals are appropriate to the patient diagnosis and current condition, is linked to a specific diagnosis and includes a paraphrased EBP rationale for ordering 5. Follow up: Follow up includes a specific time frame to return to PCP office for next scheduled appointment.

Includes EBP rationale with in text citation. Medication costs: in this section students will research the costs of all prescribed monthly medications. Students may use Good Rx, Epocrates or another resource (can use local pharmacy websites) which provides medication costs. Students will list each medication, the monthly cost of the medication and the reference source. Students will calculate the monthly cost of the case study patient’s prescribed and OTC medications. Reflect on the monthly cost of the medications prescribed. Discuss if prescriptions were adjusted due to cost. Discuss if will you use medication pricing resources in future practice. SOAP note: A focused SOAP note, written on a separate page, follows the assignment. The SOAP note is written following the provided SOAP note format. · The subjective section is organized to follow the SOAP note format. The ROS is focused, only pertinent body systems are included. · The objective section is maintained as written, no additional information is added. · The assessment section includes only the diagnoses and ICD 10 codes. Diagnosed are labeled as primary, secondary or differential diagnoses. Rationale is not required. · The plan includes 5 sections. Rationale is not required.

The assignment will be submitted through TurnItIn. Category Points % Description Assessment 50 25 Each diagnosis, primary, secondary and differential includes the ICD10 codes in parentheses next to each diagnosis. A one to two sentence paraphrased pathophysiology statement explains the diagnosis. Include pertinent positive and negative findings to support your diagnoses from the history and physical exam which links this diagnosis to your patient. Each diagnoses must include an intext citation to a scholarly reference.

NR601 Week_5 Case Study Paper: Sample Paper 

Accurate and early diagnosis facilitates effective treatment and management of a patient’s condition. As a result, a keen analysis of the patient’s presenting symptoms, social relationship, and family history help in determining the possible cause of the illnesses a patient presents with. The current study involves an analysis of the case of a 63 years old Cuban male client presenting with fatigue. The client has low energy and has gained about 10 lbs over the past year. He joined the gym and forces himself; however, he finds it difficult to sustain the exercise. The results from the gym are contrary to what the client expects. Various factors are likely to influence weight gain. Some of them include increased body fluid, fat, or muscles. Alternatively, kidney and heart failure are also linked with weight gain. Understanding the possible factors influencing the development of symptoms requires the analysis of both subjective and objective data. Besides, understanding the familial history gives useful information for making an appropriate diagnosis of the patient’s condition.

Assessment : NR601 Week_5 Case Study Paper

Primary Diagnosis  Coronary artery disease  (I25.10)

Pathophysiology: Coronary artery disease (CAD) is characterized by an insufficient blood supply in the body due to cholesterol-containing plaques blocking the coronary artery. Patients with coronary artery disease experience fatigue due to the inability of the heart to pump blood to meet the body’s requirements (Hajar, 2017).

Pertinent positive findings: The patient reported having fatigue and low energy. Fatigue is one of the major symptoms associated with coronary artery disease. Furthermore, the patient used Tylenol 500mg 2 tabs daily to manage the knee pain. Pain at the knee joint could also signify poor blood circulation in the body system. The patient has a family history of CAD, considering that his parents are deceased due to CAD. Besides, both of her siblings have CAD (Shahid & Sarwar, 2020). Furthermore, the client is overweight (weight 185 pounds). The client’s CO2 saturation level is normal, though, on the higher side (29 mEq/L) and this could suggest that the patient has an alkalosis. Finally, the patient’s lipid profile suggests coronary artery disease. The LDL cholesterol level was high while the HDL was law. The LDL value was 144mg/dl while HDL was 38mg/dl. Also, the triglycerides level was high (232mg/dl).

Pertinent negative findings: The EKG results were normal with no signs of arrhythmias or tachycardia. Also, the client’s blood pressure was within the normal range, 129/80mmHg. The respiration rate was 16 with a pulse rate of 76 bpm which are both normal. Findings from the thyroid assessment were normal.   The patient does not complain of chest pain which is a common symptom of coronary artery disease.

The rationale for the diagnosis: The patient has a family history of CAD and presents with abnormal lipid profile results. Furthermore, the patient experiences fatigue and a fairly high CO2 saturation level.

Secondary Diagnosis  Diabetes (E11.69)

            Pathophysiology A: Fatigue is a symptom encountered among diabetes patients that result from high insulin levels in the body. High insulin levels mean that the body converts sugar molecules to glycogen which are then deposited in the body mass (Erion & Corkey, 2017).

Pertinent positive findings: The patient continued to gain weight despite enrolling in the gym. He has chronic fatigue which worsens when he engaged in physical exercise. Also, cannot have enough to drink and experiences nocturia 2-3 times per day. The patient gets more hungry and thirsty upon engaging in physical exercise. The urinalysis results also suggested that the patient could be having diabetes. The presence of glucose in urine was a positive indication. The urine PH was low (5) indicating that the patient produces acidic urine.  Finally, the glycosylated hemoglobin (HBA1C) level was 6.9% which is slightly higher than the recommended value of between 4% and 5.6%.

 Pertinent negative findings: The random blood sugar level was 95mg/dl which is within the normal range.  Furthermore, the patient does not have any family history of diabetes. The renal function test results were within the normal range (Sodium 139 Potassium 4.3 Chloride 100, BUN 12 Creatinine 0.7 GFR est non-AA 92 mL/min/1.73 GFR est AA 101 mL/min/1.73).

The rationale for the diagnosis The patient experiences chronic fatigue and this could be a result of high insulin in diabetes. The urinalysis result indicated the presence of glucose in urine and this is suggestive of diabetes (Yoshida, et al., 2018).

Plan: NR601 Week_5 Case Study Paper


Lab test  (#1)  ECG

Rationale: Repeated ECG is conducted to analyze the heart functioning and the risk of heart attack or other condition associated with coronary artery disease. The test will also indicate the strength of the heart muscles and their ability to supply blood to the entire body.

Lab test (#2) Apolipoprotein B

Rationale: The test is more helpful in detecting the risk of heart attack than the low-density lipoprotein. The tests will help in the diagnosis of CAD and the risks of undesired complications.


Medication (#1) – Aspirin 75mg tablet, 1 tablet PO once a day for 30 days

Rationale. A lower dosage of aspirin is administered to reduce the risks of cardiovascular diseases. For primary prevention, 75mg of aspirin is administered daily. The dosage may be increased depending on the progress of the patient. According to Gelbenegger, et al.  (2019), aspirin reduces the risk of major adverse cardiovascular outcomes such as ischemic stroke and heart failure among others. The effect of aspirin is greater when combined with a statin. The drug prevents the formation of clots in the blood vessel that could lead to a heart attack. The clots formed in the blood vessels block the circulation of blood completely and so leading to heart attack because of the strained heart muscles. Aspirin is recommended for people with or without a history of heart disease as it helps improve perfusion.

Medication (#2) Atorvastatin 40mg tablets, 1 tablet PO four times per day for one month

Rationale: The patient’s LDL level was high with the HDL being low. Besides, the total cholesterol and triglyceride levels were high. The statin medication aims at reducing the amount of cholesterol in the blood vessels. A high level of LDL indicates an increased risk for heart attack. According to Laufs, Karmann & Pittrow (2016), the LDL level in the blood correlates to the risk of a heart attack; therefore, lowering its level should be a priority in the management of hypertension and cardiovascular diseases. A slight increase in the blood pressure reading could result in a heightened risk of heart attack among people with coronary artery disease. Statin therapy is used as secondary prevention for atherosclerotic cardiovascular disease. Also, the drug is used widely in the prevention of the genetic causes of dyslipidemia. The drug is suitable for the patient considering that he has a family history of coronary arterial disease. While the patient’s blood pressure was normal, the high levels of LDL present greater risks and so the intervention must be initiate immediately. Currently, the patient does not show any sign of a heart attack. The EKG results were normal and this an indication of the possible early stage of the CAD which can be effectively managed through the combination of aspirin and atorvastatin. According to Hadjiphilippou & Ray (2019), the choice of the medication and dosage depends on the identified risks rather than the baseline LDL only. The accumulation of the cholesterol cargo transported by the LDL within the arterial wall is the cause of atherogenesis and CAD. Using a higher dose of statin is more effective compared to a low dose in managing CAD. The treatment targets 160mg of atorvastatin daily which will significantly reduce the LDL level. The patient will be reviewed after one month and this may be adjusted depending on the patient’s progress.



The two diagnoses made based on the client’s symptoms, objective data, subjective data, and history indicates the likelihood of CAD and diabetes. Early and accurate diagnosis is necessary for effective treatment and better prognosis. On the other hand, people respond differently to the diagnosis made. Therefore, the first education goal will be to inform the client to be positive about the diagnosis. People tend to fear more especially when they realize that they have an uncommon or life-threatening condition. Emotional preparation for the patient is important in ensuring better outcomes. It will be important to let the client know that further tests may be conducted to help ascertain the diagnosis. The tests may involve imaging and other non-invasive procedures.

The patient will be educated on how to identify risky signs. The most common risk associated with CAD is a heart attack. The common signs the patient is likely to experience include pain and discomfort in the chest, nausea and vomiting, lightheadedness, and shortness of breath among others. Furthermore, the client is most likely to have urinary tract infections and this may be characterized by a burning sensation during micturition, turbid urine, lower abdominal pain, and fever. The client should be keen to note such symptoms and seek immediate medical intervention.


The effectiveness of therapeutic intervention depends on strict adherence to the prescription. Proper adherence means that the patient takes the correct dosage of the drug and at the required frequency. Therefore, the first part of medication education will involve letting the patient understand the need to adhere to the prescription given. For example, taking high doses of atorvastatin could result in difficulties in breathing and allergic reactions. On the other hand, failure to take the recommended dose may hinder the realization of the desired outcomes and the patient’s LDL levels may not reduce as expected. Also, the patient will be advised to always consult with the doctor before initiating or withdrawing a given medication. There are cases where patients seek to use alternative medications because they have not realized the desired health outcomes. The drug interactions vary with some having synergistic while others antagonistic effects. Consulting with the doctor will ensure that the patient consumes the right medication and reduce the risk of adverse drug interactions.

The patient will be educated not to take medications with alcohol. The patient takes 1-2 glasses of wine on weekends and so this makes it important to emphasize the need to abstain from wine when taking medication. The patient is already on Tylenol which he uses to manage the knee pain. A combination of aspirin, Tylenol, and alcohol over time may damage the liver.

Finally, the patient will be educated on the possible adverse reactions from the prescribed medications. The possible adverse effects of aspirin use include abdominal discomfort, headache, heartburn, cramps, and even drowsiness. In addition, the drug may cause gastrointestinal ulceration and thus be contraindicated for people with ulcers. On the other hand, the possible adverse effects of atorvastatin use include joint pain, disturbed sleeping patterns, loss of appetite, and gastrointestinal symptoms. The patient will be advised to inform his healthcare provider of any of the side effects immediately.


Dietary intake also plays a role in the development of cardiovascular risks. Besides, the patient complained of having experienced weight gain in the past. The current weight indicates that the patient is obese. Therefore, the first goal in dietary education will be to reduce weight. In this case, the patient will be advised not to consume a lot of carbohydrates and fatty meals. High consumption of refined carbohydrates is associated with the increased accumulation of glycogen in the body. Consuming non-refined carbohydrates such as whole grain in small quantities will be recommended. Also, the patient will be informed not to consume a lot of sugar considering that he has signs of high blood sugar. The high HBA1C and the presence of sugar in urine is indicating of high sugar levels. The patient can rely on the dietary management to maintain the blood sugar level.

Furthermore, the patient will be informed of the need to limit unhealthy fats and sodium. Fats are accumulated in the blood vessels and eventually reducing the size of the blood vessel lumen. The reduced lumen causes high blood pressure. Also, consuming a lot of salt results in flow-induced dilation which is likely to cause hypertension. The patient will be required to consume a lot of fruits and vegetables to boost the immune system considering that diabetes can affect the body’s defense system.


Regular exercise reduces the risk of cardiovascular disease other than helping in weight reduction. The patient has been attending gym sessions without any positive outcome. Therefore, integration of proper dietary intake with regular physical exercise will benefit him. The patient will be advised to start exercises such as jogging or cycling on daily basis to engage in moderate exercise for about 3 hours a week. Before starting the jogging or cycling, the client has to stretch about 3 to 5 times to achieve flexibility. Moderate exercise is suitable for the patient because intense exercise may be dangerous considering that his endurance ability is low. The intensity of the exercise may be adjusted with time. The patient will be encouraged to consume enough fluid during the exercise. Also, to sustain the energy required for the physical activity, he will be required to take snacks before and after the exercise.

Warning Signs for diagnoses and mediations

            Chronic fatigue could be caused by inadequate oxygen supply in the body. Alternatively, high insulin levels mean that the body will lack the glucose needed to provide energy for the basal metabolic activities and others. The first diagnosis is CAD and so this means that the patient should be on the watch out for any signs and symptoms of a heart attack which include chest pain. Such symptoms require that the patient do a regular ECG to monitor the functioning of the heart muscles and electrical conductance. Also, based on the diabetes diagnosis, the patient should closely watch for signs of dizziness or drowsiness caused by hypoglycemia. The medical intervention does not target diabetes; though, there is a possibility of the patient having the condition due to the high HBA1C. Close monitoring of the blood sugar level is required so that appropriate medication may be initiated on abnormal findings.

The warning signs for the atorvastatin include muscle pain and tenderness. The drug causes rhabdomyolysis and this can result in kidney failure. The patient should report any sign of muscle pain, dark urine, or even fever to the healthcare provider as soon as possible (Ward, Watts, & Eckel, 2019). The aspirin could also present some warning symptoms which include delayed blood clotting because the drug is a blood thinner. Occasionally, the patient may require INR tests to check for any coagulopathy.



Specialty practice or service: Cardiologist

Rationale: The patient will be referred to a cardiologist for further assessment and evaluation of the possibility of heart problems. Further tests will be conducted including the coronary artery calcium scoring among others.

Referral (#2) Endocrinologist

Rationale: The patient may require an endocrinologist’s services to determine whether fatigue is hormonally-induced. People with diabetes are likely to suffer other hormonal impairments and so seeking service from specialists may help manage the patient better.     

Follow up

            The patient will have a TCA of one month. After one month, the patient will be reviewed to determine his response to the medication. The lipid profile may be repeated to determine whether the LDL levels have changed positively. The other tests to be conducted include urinalysis, full haemogram, and ECG. Additionally, the review analyzed the patient’s progress in terms of weight management.  

Assessment of comorbidities 

Regular blood tests such as a haemogram will help in assessing the possibility of comorbidities. The presence of fever and high white blood cells could be an indication of comorbidity. Additionally, further assessment of the liver and renal function should also be assessed. The patient will also be advised to go for prostate cancer screening regularly.

Medication Cost

The patient was initiated on affordable drugs. The estimated medication cost is about $400 per month.  


The goal of the assessment was to analyze the patient’s symptoms and develop an appropriate diagnosis and treatment plan. The developed diagnoses from the patient’s objective and subjective data were coronary artery disease and diabetes. The recommended medications in the treatment plan included aspirin to enhance perfusion and atorvastatin to reduce the blood cholesterol levels. Finally, provided appropriate education as outlined above will facilitate the patient’s recovery; the education focuses on exercise, diagnosis, medication, and diet. One of the major concerns in the patient’s case is weight gain; therefore, the emphasis was made on the dietary intake and the need to engage in regular physical exercise.


Erion, K. A., & Corkey, B. E. (2017). Hyperinsulinemia: a cause of obesity?. Current obesity reports6(2), 178-186.

Gelbenegger, G., Postula, M., Pecen, L., Halvorsen, S., Lesiak, M., Schoergenhofer, C., … & Siller-Matula, J. M. (2019). Aspirin for primary prevention of cardiovascular disease: a meta-analysis with a particular focus on subgroups. BMC medicine17(1), 1-16.

Hadjiphilippou, S., & Ray, K. K. (2019). Cholesterol-lowering agents: statins—for everyone?. Circulation research124(3), 354-363.

Hajar, R. (2017). Risk factors for coronary artery disease: historical perspectives. Heart views: the official journal of the Gulf Heart Association18(3), 109.

Laufs, U., Karmann, B., & Pittrow, D. (2016). Atorvastatin treatment and LDL cholesterol target attainment in patients at very high cardiovascular risk. Clinical Research in Cardiology105(9), 783-790.

Shahid, S. U., & Sarwar, S. (2020). The abnormal lipid profile in obesity and coronary heart disease (CHD) in Pakistani subjects. Lipids in health and disease19, 1-7.

Ward, N. C., Watts, G. F., & Eckel, R. H. (2019). Statin toxicity: mechanistic insights and clinical implications. Circulation Research124(2), 328-350.

Yoshida, S., Miyake, T., Yamamoto, S., Furukawa, S., Niiya, T., Senba, H., … & Hiasa, Y. (2018). Relationship between urine pH and abnormal glucose tolerance in a community‐based study. Journal of diabetes investigation9(4), 769-775.




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