Patient’s Diagnosed with HIV/AIDS with Pneumonia Case Study Important Instruction about the Assignment · You will then formulate your differential diagnoses list, develop a plan of care, and submit a written clinic note documenting your care of this patient

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Patient’s Diagnosed with HIV/AIDS with Pneumonia Case Study

Important Instruction about the Assignment

· You will then formulate your differential diagnoses list, develop a plan of care, and submit a written clinic note documenting your care of this patient. Your differential diagnoses list should consist of 4 diagnoses, including 1 of which is your final diagnosis.

 

· Please briefly describe your rationale and reasoning for why you would include or rule out a diagnosis in your working diagnosis list. Provide 6 research nursing and medical references for your rationale.

 

· The paper should always have an introduction statement that explains what the paper will entails.

· Remember to include a cover page and use the most recent update APA formatting for references.

· Refer to the SOAP NOTE TEMPLATE for details on how this assignment will be graded.

· For this paper, you must provide 12-15 pages well written evidence-based research paper according to the rubric guidelines, follow the APA format formatting for references and support your paper with at least 5 to 7 nursing or medical evidence-based research articles not older than 7 yrs.

· please take time to read and review it, if the paper is not up a master’s degree level standard, I will not accept the work. I just want to be clear about that before I assigned it to anyone. This is an advanced degree work that requires a very strong writer with the background and experience in Nursing and Medical field and a very well-developed English and written expertise.

 

 

 

Patient’s Soap Note

Hint 1 (HIV/AIDS with Pneumonia) is the patient primary diagnosis.

 

Patient Chief Complaint:

I’ve had a fever on and off for the last 3 weeks or so. He had lost 5 pounds. Not exercising, he has a dry cough and get winded walking up the stairs or walking multiple feet’s on a regular surface. His diet remains the same with no recent changes, he has elevated fever. He has traveled to few states and other country. Past history of working in a latex company in the past and that’s the only toxic exposure substances he’s aware of. He also worked for a company that requires a tuberculosis testing. His last test was done a month ago and his test was negative. Patient is also a smoker and occasionally drinks. Patient mom has a high blood pressure with history of breast cancer however she’s still alive. His father is alive with history of emphysema, and smokes. His brother has asthma and currently enrolled in the military. He sometimes use protection during intercourse but not all the time. He doesn’t use any recreation drugs. He has also had multiple partners in the last year and unsure if they are symptomatic. He also stated to be sexually active with the same sex (Men to Men). Patient also noticed some skin flakiness however did not pay much attention to it. Patient physical assessment showed history of tachypnea, hypoxia and fever.

 

Reliability and Source of History:

The patient is alert and oriented and able to answer all of the questions.

Subjective and Objective Data.

Hint 1 (Patient primary diagnoses is HIV/AIDS with Pneumonia ) other potential diagnoses are:

 

1. Asthma

2. Pneumonia, Viral

3. Pulmonary embolism

4. COPD

 

Assessment

The primary diagnoses is HIV/AIDS with Pneumonia. Other potential hypothesis for this patient includes Asthma, Pneumonia with Viral, Pulmonary embolism and COPD. The patient primary diagnosis will be based on his subjective and objective data, nurse practitioner objective data, laboratory information data and physical assessments.

 

The Patient main diagnosis is HIV/AIDS with Pneumonia

Rationale for Choosing HIV/AIDS with Pneumonia

The patient other potential hypothesis diagnoses include:

5. Asthma

6. Pneumonia, Viral

7. Pulmonary embolism

8. COPD

Asthma: is

Rationale for not choosing this diagnosis

Pneumonia, Viral: is

Rationale for not choosing this diagnosis

Pulmonary Embolism: is

Rationale for not choosing this diagnosis

COPD

Rationale for not choosing this diagnosis

Hint 2

 

Patient treatment plan which should include the up-to-date treatment for HIV/AIDS with Pneumonia

Elaborate …

· Process on informing the patient about being diagnosed with HIV Positive.

· Should include initiation sulfamethoxazole/trimethoprim therapy

· Initiate prednisone

· Complete baseline HIV Testing

· Assess for short-interval antiretroviral therapy (ART) initiation

· HIV counseling

· Patient Education – should include treatment of all known recent partners the patient had sex with (elaborate).

· Teaching regarding protection during any sexually activities (elaborate)

· Teaching regarding the risk of STD ( Elaborate)

· And many more please.

 

(This is very important)

 

Hint 3

Patient lab should include all below and please explain the rationale for these labs with references to support it.

 

Laboratory order:

· D-dimer

· Human immunodeficiency virus (HIV) antibody

· Human immunodeficiency virus (HIV), P24 antigen

· CBC Complete Blood count

· Cryptococcus antigen screen

· Blastomyces antigen, urine

· Human immunodeficiency virus, Viral load

· Lactate dehydrogenase (LDH)

· Cluster of differentiation 4 (CD4)

· Blood culture and sensitivity

· Sputum immunofluorescent staining for PCP

· Influenza PCR (Nasal swab)

· Arterial blood gases (ABG)

· Histoplasma antigen, urine

· Neisseria gonorrhea swab/PCR

· Human immunodeficiency virus (HIV), Western blot

· Basic metabolic panel (BMP)

· Sputum culture and sensitivity (SCS)

· Chest X-ray AP

 

Care plan

Nursing Intervention

Treatment

Treatment

Process on informing the patient about being diagnosed with HIV Positive.

Should include initiation sulfamethoxazole/trimethoprim therapy

Initiate prednisone

Complete baseline HIV Testing

Assess for short-interval antiretroviral therapy (ART) initiation

HIV counseling

And many more please.

 

· Pharmacological:

· Non-pharmacological:

· Patient Education

· Referrals and the follow-up

Conclusion