Audio Transcript Auto-generated
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Hello. My name is veronica
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and
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I am presenting my signature soap note.
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I am at Fletcher Family Clinic.
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It's a family clinic.
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So let's get started with the case.
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I have a 32 year old Hispanic male who
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To present it to the clinic
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with a nose bleed for a few times a week.
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He's a 32 year old male
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and he had a nosebleed this week while at work which lasted a few times.
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He applied pressure to stop the bleeding.
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Nothing makes a nosebleed better. He has tried to
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put some baseline at night to keep the skin moist but reports it does not help.
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He has an electrician so he is regularly outside and exposed to
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the heat of the day on different days of the different environments.
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He denies any allergies, itchy nose, watery eyes or discharge.
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He denies recent illness and does not have shortness of breath.
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He has no other complaints except for the nose bleed and has been
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told he has high blood high blood pressure readings in the recent past.
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Now,
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the reason this case is important to me
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is because he's a monolingual spanish speaker.
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And um I thought the case was interesting because what prompted him to go
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to the doctors was not necessarily what others might be prompted was the nosebleed.
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That is
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rightfully or not associated with high blood pressure.
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And his concern for that and the case is interesting to
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me because I felt like I did make some headway.
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I also feel that this case is
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an important case because we'll be seeing these types of cases a lot in our clinic and
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we do have a lot of power as nurse practitioners and we really can't influence
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people in a positive way, Not all the time, but once in a while.
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And when that happens it feels great
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and that's what it's all about. So that's why I chose this case. So
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let's see.
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So he
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is with multiple partners, has eight year old son,
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He smokes a pack a week and he's been trying to quit but unsuccessful.
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He drinks 6 to 12 beers divorced and he tries to eat better and he has lots of sleep.
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He has seven hours of sleep and he has stress related to work,
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let's see. And
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um, in terms of his review of systems, the one thing that stuck out for me was that he,
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um,
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every, you know, on the surface,
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everything was pretty normal and unremarkable except for his complaint of his,
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you know, bloody nose
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and when we look at his vitals,
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His blood pressure was elevated 150 over 80 for
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his historic readings had been sometimes higher than that.
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Um,
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he also,
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the other reason that I thought this case was interesting was
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because I got to look inside his nose and see um,
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what it looks like without having to see it from pictures.
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So that was, um, albeit a simple experience,
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an important one because it's one thing to look at
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any buy part or
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um, disease in a picture.
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And it's another thing when you get to actually look inside the nose and see
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what it looks like when a person has had a history of recent nosebleeds.
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So I thought that was also interesting to me.
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So um besides the elevated blood pressure and the
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um
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he had everything else was pretty normal except that he had
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yellowing nails, especially the forefinger and middle finger,
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which is indicative of a person
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that smokes.
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And his
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nose was symmetrical and he had patent nares except he had
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positive dilated vessels in the nares bilaterally with dry mucous membrane.
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So
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for his um
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the other thing that was interesting about this case was his cholesterol was 1
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79 his LDL was 1 43 which was high and his triglycerides were high
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And his HDL was at 43 and his
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literal sclerosis cardiovascular disease risk was at 48.
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The reason that
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I found this case to be particularly interesting is because if
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you just change that one factor that he isn't smoking,
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the calculator score goes down to almost zero.
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So
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with this common finding I just realized or
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just remembered how important it is to encourage
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our patients that this one thing that they can do can really change their lives and
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It absolutely changes the score so dramatically that it
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goes up to almost 50% when they smoke.
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So I kind of had a conversation with him about that.
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And he had also shared in his um social when,
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when he was sharing his social history findings
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that his father had recently passed of a heart
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attack and he was worried about his own health
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and he was trying to change his lifestyle.
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So we kind of had a really interesting conversation
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and we'll get to that in a little bit.
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So I was able to share some resources and I felt like
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he really was going to try his best to quit smoking,
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given all these other factors.
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And he did feel comfortable speaking with me about
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something that had happened to him which was,
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his father had passed.
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And I feel like because I spoke spanish,
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I was able to communicate with him in a way that made him feel comfortable
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and so that we could work together.
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So his differential diagnosis for episode axis was um I
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determined that this was his diagnosis because he had,
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he was positive for localized dilation of blood vessels upon inspection.
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He had dry mucous membranes and the weather has been cold and dry in recent months.
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So those are all things which would contribute or tribute to episode axis.
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And I also ruled out acute sinusitis because the patient
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is negative for pure talent discharge or facial pressure.
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He also was negative for non allergic rhinitis,
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although the patient smokes and that could be a trigger,
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he is negative for swollen beefy to burn AIDS,
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kabul stoning of the posterior bearings from post nasal discharge.
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He denied sneezing and itching or coughing that is
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or a cough that is consistent or chronic.
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The other
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diagnosis I ruled out was
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a nasal foreign object because there was nothing inside
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his nose when I looked and for hypertension.
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The patient has previously presented with high
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blood pressure readings and lifestyle modifications um
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That he has tried
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and differential diagnosis included
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um
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secondary to hyper
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hyper lipid E. Mia.
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But although his LDL is elevated the cholesterol findings
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do not warrant a statin at this time.
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And that's not only according to cash and glass but also to the atherosclerosis,
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cardiovascular disease risk calculator.
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He also I rolled out hyperthyroidism due to the dry mucous membranes fatigue
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which could be possible signs.
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But he had he did not have an abnormal TSH at
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the last labs which was prior to this one months ago.
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I also ruled out reno stenosis.
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It's not likely as we have not seen that there is any instability,
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inability to control his hypertension.
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So
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once I determined his diagnosis,
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we did speak some more and we generated a plan together.
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Our plan included a treatment of um I was going to order labs a cbc CMp, a lipid panel,
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a thyroid stimulating panel on a one c micro albumin and
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labs to check for possible chronic kidney disease anemia hypothyroidism.
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I also wanted to check for coagulation studies such as P. T. A. P. T. T. And T. T.
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To rule out any coagulation issues kogel opa these um
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For his pharmacology, we were going to start with Lucinda April
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10 mg once daily and we would increase that if needed. Up to 40 mg.
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And the other thing we were gonna do is we're gonna start him off on
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nicotine replacement therapy given patches.
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He has never tried any and
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his preference, patient preference.
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So there's different forms of nicotine replacement theory.
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But after speaking with him we decided we were going
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to go with patches because it was his preference.
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And so it was going to be 21 mg once a day for
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4 to 6 weeks followed by 14 mg once a day for two weeks
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and tight trading followed by seven mg once a day for two weeks
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plus short acting nicotine doses as needed in the form of otc gum.
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And then we educated him on the side effects of blood pressure medication.
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I gave him printed materials in spanish
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we discussed
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lifestyle and diet sodium reduction of less than 1.5 mg a day,
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a dash diet which included 8 to 10 servings of vegetables, whole grains, low fat
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proteins, 30 minutes of physical increased activity, five days a week,
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limit alcohol consumption to two drinks a
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week and stop smoking for smoking sensation.
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Um I also gave him a website which is being funded by the County of Los
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Angeles where they offer you your own smoking
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cessation coach and I showed him on the website
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where he could access it where he could access it in spanish.
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And I helped him navigate that because he also had some um
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technology,
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he wasn't so technology technologically savvy and so I kind
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of supported him as he was learning new ways to access
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the internet. So
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that was also very effective.
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And um we also
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advised him to return if he feels more than four of the following
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within 24 hours and not due to another condition which includes irritability,
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anger, frustration, anxiety, difficulty concentrating, increased appetite,
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restlessness,
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depressed mood or insomnia as these are related to tobacco withdrawal.
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And he may need
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additional treatment.
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And then we reviewed the A. S. C. V. D.
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Calculator and I showed him how his risk went from 0 to 48 because he smokes
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and I explained it's the most important action he
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can take for his improved quality of health.
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And we also referred him to behavioral counseling
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and to follow up one month or sooner.
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So again this case was memorable to me it's important
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because we get a lot of these all the time.
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It's important because we as nurses can influence our patients
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and encourage them and support them to make just one
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change and one change to make a huge difference in
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their quality of lives for the way that they age
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and in this whole process I leaned into
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gene Watson Caritas balance which is about learning,
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it's about engaging in in trans personal teaching and learning within
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the context of a caring relationship and also co creating,
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creating a healing environment
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that was comfortable for him to learn.
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Thank you so much. And I look forward to
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seeing all of you at graduation.