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NR 601 Week 2 Case Study Discussions Physical Examination (Part-1) NEW

Discussion Part One (graded)

B.J., a 70-year-old Caucasian female has been seen in the clinic several times over the last 3 years. However, she missed her last annual appointment-last appointment was 18 months ago and today you are the nurse practitioner seeing her. She arrived to the clinic alone and states she is “here for my check-up”.  

Background:

The patient reports that “my feet just burn and tingle all the time and it is so much worse at night that I can hardly sleep at all”. She also indicates that “I need some new pillows; I use 3 of them now to just get comfortable at night to sleep. Those pillows help me catch my breath so I can sleep better”.  She also reports dyspnea just walking to the bathroom, but it only happens when her legs are “swole up” and also states, “the coughing also keeps me up at night”.  To be honest, “I’m just tired in general whether my feet are “swole” or not”. She also indicates that she cannot see well, especially at night. She also reported that at her last visit to the clinic, she was told that she had a “heart beat problem” and that she is supposed to be taking aspirin every day. She said she thinks all of her “heart pains” went away after she started taking the aspirin and “putting that pill under the tongue”.  One of her concerns she has today is that since her husband died last year, she tells you, “I just don’t like doing things that I liked to do before my husband died. We used to like to do all sorts of stuff, but anymore….I just feel blue all the time”.

PMH:

Chronic back pain

Hypertension

Previous history of MI in 2010

Diabetes?

Hypothyroidism?

Constipation?

Congestive Heart Failure?

Current medications: 

            Coreg 6.25 mg PO BID

            Colace 100 mg PO BID

            Glucotrol XL 10 mg PO daily

            Lantus insulin 20 units at HS

            K-dur 20 mEq PO QD

            Furosemide 40 mg PO QD

            L-Thyroxine 112 mcg PO QD

Aspirin?

Nitroglycerine?

Surgeries:

2010-Left Anterior Descending (LAD) cardiac stent placement Allergies: Amoxicillin

Vaccination History:

She receives an annual flu shot. Last flu shot was this year Has never had a Pneumovax

Has not had a Td in over 20 years

Has not had the herpes zoster vaccine

Other:

Has not seen a dentist in over 15 years, the time she got her dentures

Last colorectal screening was 11 years ago

Last mammogram was 5 years ago

Has never had a DEXA/Bone Density Test

Last dilated eye exam was 4 years ago

Labs from last year’s visit: Hgb 12.2, Hct 37%, Hgb A1C 8.2%, K+ 4.2, Na+140,Cholesterol 186, Triglycerides 188, HDL 37, LDL 98, TSH 3.7, ALT/AST WNL.

Social history:

She graduated from high school, and thought about college, but got married right away and then had kids a short time later. Her two sons and their wives live with her, take her to church and to the local senior center; they do all the cleaning, run errands, and do grocery shopping. Family history:

Both parents are deceased. Father died of a heart attack; mother died of natural causes.  She had one brother who died of a heart attack 20 years ago at the age of 52.

Habits:

Patient is a current tobacco user and has smoked 1 pack of cigarettes daily for the last 50 years and reports having no desire to quit. She uses occasional chew.  She drinks one 4 ounce glass of red wine daily.

  Discussion Part One:

 Provide differential diagnoses (DD) with rationale.

Further ROS questions needed to develop DD.

Based on the patient data provided, choose geriatric assessment tools that would be appropriate to use in conducting a thorough geriatric assessment. Provide a rationale on why you are choosing these particular tools.

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NR 601 Week 6 Case Study Discussions Health Promotion, Health Protection, Disease Prevention, and Treatment Considerations in Long-Term Care (Part-2) NEW

Discussion Part Two (graded)

 Physical Exam:

Discussion Part Two (graded)

Vital signs: blood pressure 145/90, heart rate 100, respirations 20 height 5’1”; weight 210 pounds

Labwork:

CBC: normal

UA: 2+ glucose; 1+ protein; negative for ketones

CMP: BUN/Creat. elevated; Glucose is 300 mg/dL

Hemoglobin A1c: 12%

Thyroid panel: normal

LFTs: normal

Cholesterol: total cholesterol (206), LDL elevated; HDL is low EKG: normal

General: obese female in not acute distress HEENT: unremarkable

CV: S1 and S2 RRR without murmurs or rubs

Lungs: Clear to auscultation

Abdomen– soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits

Discussion Questions Part Two

 For the primary diagnosis, what non-pharmacological and pharmacological strategies would be appropriate?

Include the following: lab work and screenings to be completed. Describe patient education strategies.

Describe follow-up and any referrals that may be necessary.

Discussion Part One (graded)

C.G. is a 69-year-old male with a history of right head and neck cancer that you have been following for one year. The carcinoma was initially localized to the head and neck-specifically at the left lingual tonsil region and went on to complete a total of 6 weeks of radiation and chemotherapy. Recently, the last PET scan indicated some metabolic activity in the left lymph node area along with other regions of abnormal metabolic activity in the body-particularly the liver and the lungs indicating metastasis. C.G. indicates that he is tired of the effects of chemotherapy and radiation and does not want to pursue any more treatment for cancer.

Background:

Right head and neck cancer with metastasis to liver and lungs; patient is refusing further treatment.

PMH:

Hypertension

Hyperlipidemia

Stomatitis

Anemia

Neutropenia 

Current medications: 

Carvedilol 12.5 mg po 1 daily

Furosemide 40 mg po daily

Surgeries:      

2012: right radical neck dissection 

Allergies:

None 

Vaccination History:

Influenza vaccine last received 1 year ago

Received pneumovax at age 65

Received Tdap 5 years ago

Has not had the herpes zoster vaccine 

Social history and Risk Factors:

Former smoker-stopped smoking at the time his cancer was diagnosed-2 years ago

Negative for alcohol intake or drug use

Patient does not have an advanced directive or living will. He is refusing further treatment for his cancer and his wife and children are in disagreement with him. The patient wants to know what his options are for the remainder of his life.  

Family history:

Negative 

 Discussion Part One:

 Provide differential diagnoses (DD) with rationale.

Further ROS questions needed to develop DD.

Identify the legal/ethical issues involved with the patient and describe your approach to addressing end-of-life care for this patient.

Discussion Part Two (graded)

 Physical examination:

Vital Signs: Height:  6’0   Weight: 140 pounds; BMI: 19.0   BP: 156/84  P: 84 regular R: 20

HEENT: normocephalic, symmetric PERRLA, EOMI; poor dentition NECK: left neck supple; non-palpable lymph nodes; no carotid bruits. Limited ROM

LUNGS: rhonchi in anterior chest bilaterally.

HEART: S1 and S2 audible; regular rate and rhythm

ABDOMEN: active bowel sounds all 4 quadrants; Normal contour; RUQ tenderness; liver palpable

NEUROLOGIC: negative

GENITOURINARY: negative

MUSCULOSKELETAL: negative

PSYCH: PHQ-9 is 15

SKIN: oral mucosa irritated-stomatitis

 Discussion Part Two:

Summarize the history and results of the physical exam. Discuss the differential diagnosis and rationale for choosing the primary diagnosis. Include one evidence-based journal article that supports your rationale and include a complete treatment plan that includes medications, possible referrals, patient education, ICD 10 Codes, and plan for follow up.

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