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NR 601 Week 5 Case Study Discussions Physical Examination  (Part-2) NEW

Discussion Part Two (graded)

 Physical examination:

Vital Signs:

Height:  5’8”   Weight: 154 pounds BMI: 23.4   BP: 132/76    P: 76  regular    R: 16

HEENT: Normocephalic, symmetric. PERRLA, EOMI, no cataracts noted; poor dentition.

NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. LUNGS: Respirations are unlabored, decreased breath sounds and crackles at the bases bilaterally. Prolonged expiratory phase throughout lung fields, inspiratory wheezes and a productive cough of cloudy white sputum.

HEART: RRR with regular without S3, S4, murmurs or rubs. 

ABDOMEN: Round, firm abdomen; active bowel sounds;  non-tender. NEUROLOGIC: Unsteady gait, swaying while standing during periods of agitation. Achilles reflexes are present bilaterally. Strength is equal but decreased in the upper and lower extremities bilaterally.

GENITOURINARY:  Urinary incontinence with strong odor of urine. NO CVA tenderness.

MUSCULOSKELETAL: Mild kyphosis. Heberden’s nodes at the distal interphalangeal joints (DIP) of all fingers, and marked crepitus of the bilateral knees on flexion and extension. Pedal pulses palpable. No edema noted in lower extremities.

 PSYCH: Manic, restless, angry and hyperverbal

SKIN: Right forearm with 3 cm x 5 cm x 0 cm dry, scabbed abrasion. Left forearm with 4 cm x 5 cm x 0 cm dry, scabbed abrasion.

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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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