#NR 601 Week 3 Case Study Discussions Physical Examination (Part-2) NEW
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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 3 Case Study Discussions Physical Examination (Part-2) NEW
Discussion Part Two (graded)
Physical examination:
Vital Signs:
Height: 5’0” Weight: 150 pounds BMI: 29.3 BP: 120/64 T: 98.0 oral P: 68 regular R: 16, non-labored
HEENT: Normocephalic, symmetric. Evidence of prior cataract surgery
in both eyes. PERRLA, EOMI, cerumen impaction bilateral ears.
NECK: Neck supple; non-palpable lymph nodes; no carotid bruits.
LUNGS: Clear to auscultation
HEART: RRR with regular without S3, S4, murmurs or rubs.
ABDOMEN: Normal contour; active bowel sounds, LLQ tenderness.
PV: Pulses are 2+ BL in upper and lower extremities; no edema. No
evidence of peripheral neuropathy.
NEUROLOGIC: Negative
GENITOURINARY: No CVA tenderness
MUSCULOSKELETAL: Gait fluid and steady. No muscle atrophy or
asymmetry. Full ROM all joints. Strength 5/5 and equal bilaterally. Joint swelling in fingers both hands.
PSYCH: Flat affect; patient declined to answer PHQ-9 and GDS
SKIN: Grossly intact without rashes or ecchymosis.
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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NR 601 Week 1 Case Study Discussions Physical Examination(Part 1) NEW
Discussion Part One (graded)
You meet your first patient of the morning. A.K. is a 65-year-old Caucasian male who you are seeing for the first time. Both wife and daughter are present.
Background
He reports that he has had an 18-pound unintentional weight loss in the last 2 months “I am just not hungry anymore, and when I do eat, I get full so fast. In fact, it is really hard to eat, and I don’t eat nearly as much as usual, even though I eat 3 times every day”. He also reports feeling more tired than usual. “I am not sleeping very well. My wife wakes me up when I am snoring, or when she thinks I am not breathing. I used to have sleep apnea, but I don’t think I have it anymore. Besides, that mask is so horrible to wear.” He reports day time somnolence. He reports that he is at the clinic today because of his wife and daughter’s concern about his weight loss and loss of appetite.
PMH
Mr. A.K. has a history of hypertension, cataracts, and osteoarthritis.
Current medications:
Ibuprofen 600 mg po TID
Lisinopril 20 mg po QD
Hydrochlorothiazide 25 mg PO QD
Simvastatin 20 mg po QD
Vitamin D3 50,000 units po weekly
Omeprazole 40 mg po QD
Sudafed 50 mg po TID prn
Surgeries
April 2010-Right cataract extraction with Intraocular Lens Placement
June 2010- Left cataract extraction with Intraocular Lens Placement
November 2011-Left total knee arthroplasty
Allergies: No known drug or food allergies. Allergies to latex causing difficulty breathing and to bee stings, causing widespread edema and airway obstruction.
Vaccination History
He receives annual flu shots “most of the time”. His last one was 18 months ago.
Received a Pneumovax “the day I turned 65”.
His last TD was greater than 10 years ago.
Has not had the herpes zoster vaccine.
Social history
He has an 8th grade education and is a retired concrete finisher. He lives with his wife of 45 years and his daughter lives next door. He enjoys working in his back yard garden and recently tripped over the garden hose last week where his neighbor had to come and help him up.
Family history
Both parents are deceased. Father died of a heart attack at the age of 80; mother died of breast cancer at the age of 76. He has one daughter who is 45 years old and has hypertension. Hypertension, coronary artery disease, and cancer runs in the family.
Habits
He drinks one 4 ounce glass of red wine nightly; previous smoker of 30 years; he quit for 10 years, and is now smoking ¼ pack per day for the last 6 months.
Discussion Part One:
Provide the differential diagnoses (DD) with rationale
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NR 601 Class Homework
NR 601 Class Homework
NR 601 week 1 A. K. part 1
NR 601 week 1 A. K. part 2
NR 601 WEEK 1 GERITRICS PRACTICUM PART 1
NR 601 WEEK 1 GERITRICS PRACTICUM PART 2
NR 601 Week 1 MAT ADLT SOAP 2
NR 601 Week 2 MAT ADLT Part 1
NR 601 Week 2 MAT ADLT Part 2
NR 601 Week 2 MAT ADLT SOAP 2
NR 601 Week 3 Part 1
NR 601 Week 3 Part 2
NR 601 Week 4 Part 1
NR 601 Week 4 Part 2
NR 601 Week 6 Part 1 Patient Information
NR 601 Week 6 Part 2 Patient Information
NR 601 Case Study Presentation Summary
NR 601 WEEK 1 GERITRICS PRACTICUM PART 1
Background
PMH
Surgeries
Vaccination History
Social history
Family history
Habits
Differential Diagnosis:
Abnormal weight loss
Depression, Depressive Episode F 32.9
Sleep Apnea
Physical Exam and Diagnostics
NR 601 WEEK 1 GERITRICS PRACTICUM POST 2
You meet your first patient of the morning. A.K. is a 65-year-old Caucasian male who you are seeing for the first time. Both wife and daughter are present.
Background
He reports that he has had an 18 pound unintentional weight loss in the last 2 months “I am just not hungry anymore, and when I do eat, I get full so fast. In fact, it is really hard to eat, and I don’t eat nearly as much as usual, even though I eat 3 times every day”. He also reports feeling more tired than usual. “I am not sleeping very well. My wife wakes me up when I am snoring, or when she thinks I am not breathing. I used to have sleep apnea, but I don’t think I have it anymore. Besides, that mask is so horrible to wear.” He reports day time somnolence. He reports that he is at the clinic today because of his wife and daughter’s concern about his weight loss and loss of appetite.
PMH
Mr. A.K. has a history of hypertension, cataracts, and osteoarthritis.
Current medications:
Ibuprofen 600 mg po TID Lisinopril 20 mg po QD Hydrochlorothiazide 25 mg PO QD Simvastatin 20 mg po QD Vitamin D3 50,000 units po weekly Omeprazole 40 mg po QD Sudafed 50 mg po TID prn
Surgeries
April 2010-Right cataract extraction with Intraocular Lens Placement
June 2010- Left cataract extraction with Intraocular Lens Placement
November 2011-Left total knee arthroplasty
Allergies: No known drug or food allergies. Allergies to latex causing difficulty breathing and to bee stings, causing widespread edema and airway obstruction.
Vaccination History
He receives annual flu shots “most of the time”. His last one was 18 months ago.
Received a Pneumovax “the day I turned 65”.
His last TD was greater than 10 years ago.
Has not had the herpes zoster vaccine.
Social history
He has an 8th grade education and is a retired concrete finisher. He lives with his wife of 45 years and his daughter lives next door. He enjoys working in his back yard garden and recently tripped over the garden hose last week where his neighbor had to come and help him up.
Family history
Both parents are deceased. Father died of a heart attack at the age of 80; mother died of breast cancer at the age of 76. He has one daughter who is 45 years old and has hypertension. Hypertension, coronary artery disease, and cancer runs in the family.
Habits
He drinks one 4 ounce glass of red wine nightly; previous smoker of 30 years; he quit for 10 years, and is now smoking ¼ pack per day for the last 6 months.
Discussion Part One:
Provide the 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.
NR 601 MAT ADLT WEEK 1 SOAP 2
NR 601 MAT ADLT WEEK 2 SOAP 2
PMH:
Chronic back pain
Hypertension
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL: No reports anorexia, nausea, vomiting or diarrhea or abdominal pain or blood.
GENITOURINARY: No reports of frequency, urgency, burning
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, Reports numbness and tingling in the lower extremities “my feet just burn and tingle all the time and it is so much worse at night”
No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No reported anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety;
ENDOCRINOLOGIC: Diabetic current treatment includes insulin and oral hyperglycemic; currently taking L-Thyroxine
ALLERGIES: Allergic to amoxicillin, No history of asthma, hives, eczema or rhinitis.
Physical examination:
Vital Signs
Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8 BP 110/70 T 98.0 po P 100 R 22, non-labored; Urinalysis: Protein 2+, Glucose: 4+
HEENT:tinnitus
NECK:
LUNGS: Decreased breath sounds in bases bilaterally with rales,
HEART: Irregularly irregular rhythm; Unable to detect S3 or murmur
ABDOMEN: Normal contour;
PV:
NEUROLOGIC:
GENITOURINARY:
MUSCULOSKELETAL: .
PSYCH:
SKIN:
NR 601 MAT ADLT WEEK 2 PART 1 AND PART 2
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:
PMH:
Chronic back
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
Differential Diagnosis:
Heart Failure, Unspecified
Rationale:
The reported symptoms of distal tingling and burning in her feet supports the diagnosis of the condition neuropathy which includes paresthesia pain, sensation of burning in affected area (Hennion & Siano, 2013).
Peripheral Arterial Disease I73.9 (“icddata.com,” 2016)
Peripheral arterial disease (PAD) is atherosclerosis leading to narrowing of the major arteries distal to the aortic arch. It can involve both the upper and lower extremities. Progressive occlusion results in arterial stenosis, reduced blood flow, and claudication (Hennion & Siano, 2013).
HPI:
Onset: Not specified
Location: lower extremities. Chest
Duration: All the time, worse at night
Characteristics: burning, tingling, fatigue, SOB
Aggravating Factors: activities, exertion, Nighttime
Relieving Factors: pill taken under tongue
Treatment: pill under tongue
Current medications:
Coreg 6.25 mg PO BID
Allergies: Allergic to amoxicillin, No history of asthma, hives, eczema or rhinitis.
PMH:
Chronic back pain
Hypertension
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:
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NR 601 Week 2 Case Study Discussions Physical Examination (Part-2) NEW
Discussion Part Two (graded)
Physical examination:
Vital Signs
Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8 BP 110/70 T 98.0 po P 100 R 22, non-labored; Urinalysis: Protein 2+, Glucose: 4+
HEENT: normocephalic, symmetric. Bilateral cataracts; PERRLA, EOMI; Upper and lower dentures in place a fitting well. No tinnitus
NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. Thyroid non-palpable
LUNGS: Decreased breath sounds in bases bilaterally with rales, expiratory wheezing with prolonged expiratory phase noted throughout all lung fields. No costovertebral angle tenderness (CVAT) noted. Increase in AP diameter noted.
HEART: Irregularly irregular rhythm; Unable to detect S3 or murmur
ABDOMEN: Normal contour; active bowel sounds all four quadrants; no palpable masses.
PV: Pulses are 2+ in upper extremities and 1+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally;
NEUROLOGIC: Achilles reflexes are hypoactive bilaterally. Vibratory perception to the 128 Hz tuning fork placed at the MTP of her great toe is absent bilaterally; She is unable to discern monofilament placement in 3 locations on her left foot and 2 places on her right foot.
GENITOURINARY: no CVA tenderness; not examined
MUSCULOSKELETAL: Heberden’s nodes at the DIP joints of all fingers and crepitus of the bilateral knees on flexion and extension with tenderness to palpation medially at both knees. Kyphosis and gait slow, but steady.
PSYCH: normal affect; her Mini-Cog Score is 3. Her PHQ-9 score is 22.
SKIN: Sparse hair noted on lower legs and feet bilaterally with dry skin on her ankles and feet.
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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NR 601 Week 3 Case Study Discussions Physical Examination (Part-2) NEW
Discussion Part Two (graded)
Physical examination:
Vital Signs:
Height: 5’0” Weight: 150 pounds BMI: 29.3 BP: 120/64 T: 98.0 oral P: 68 regular R: 16, non-labored
HEENT: Normocephalic, symmetric. Evidence of prior cataract surgery
in both eyes. PERRLA, EOMI, cerumen impaction bilateral ears.
NECK: Neck supple; non-palpable lymph nodes; no carotid bruits.
LUNGS: Clear to auscultation
HEART: RRR with regular without S3, S4, murmurs or rubs.
ABDOMEN: Normal contour; active bowel sounds, LLQ tenderness.
PV: Pulses are 2+ BL in upper and lower extremities; no edema. No
evidence of peripheral neuropathy.
NEUROLOGIC: Negative
GENITOURINARY: No CVA tenderness
MUSCULOSKELETAL: Gait fluid and steady. No muscle atrophy or
asymmetry. Full ROM all joints. Strength 5/5 and equal bilaterally. Joint swelling in fingers both hands.
PSYCH: Flat affect; patient declined to answer PHQ-9 and GDS
SKIN: Grossly intact without rashes or ecchymosis.
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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NR 601 Week 4 Case Study Discussions Physical Examination (Part-1) NEW
Discussion Part One (graded)
You are seeing S.F., a 74-year-old. Hispanic male in the office this morning for difficulty breathing.
Background:
S.F. presents with increased dyspnea on exertion that has become progressively worse over the last 3 days. You observe that he is using pursed lip breathing as he explains his chief complaint. He reports that he has been coughing up a moderate amount of thick, green sputum for approximately one week that was accompanied by a fever of 100.6 and chills. He took Ibuprofen 400 mg every 4 hours and increased his fluid intake for the last week. Two days ago he noticed that the sputum is now yellow rather than green and that he has not experienced any more fever. Overall, he feels like he is getting better. However, the dyspnea on exertion developed three days ago without relief despite the use of his Spiriva HandiHaler. He reports that he lost his rescue inhaler and has not had it to use in over 2 months.
PMH:
COPD
Hypertension
Osteoarthritis
Current medications:
Asprin-81 daily
Cyclobenzaprine 10 mg prn
Meloxicam 15 mg daily
Metoprolol 25 mg daily
Spiriva HandiHaler daily as directed
Tramadol 50 mg daily prn
Surgeries:
Appendectomy as a child (date unknown)
2004-Left cataract extraction with intraocular lens placement
2008-Right cataract extraction with intraocular lens placement
Allergies: NKA
Vaccination History:
Influenza vaccine- October 2013
Pneumovax-2010
His last TD-can’t remember
Has not a TDAP/TD in 20 years
Screening History:
Last Colonoscopy was 2012-normal
Last dilated retinal and glaucoma exam was 2013
Social history:
Retired roofer-stopped working in 2004 due to arthritis and pain in his rotator cuff. Is married and lives with spouse. They have 4 grown children who live within a 10 mile radius of them. Currently smokes-is down to ½ pack cigarettes daily. Has smoked for 45 years total.
Family history:
Father is deceased and had a history of hypertension and diabetes; Mother is deceased and had a history of CAD/MI; Sister-history of colon cancer.
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 Entire Course NEW
NR 601 Week 1 Case Study Discussions Physical Examination (Part 1) NEW
NR 601 Week 1 Case Study Discussions Physical Examination (Part 2) NEW
NR 601 Week 2 Case Study Discussions Physical Examination (Part-1) NEW
NR 601 Week 2 Case Study Discussions Physical Examination (Part-2) NEW
NR 601 Week 3 Case Study Discussions Physical Examination (Part-1) NEW
NR 601 Week 3 Case Study Discussions Physical Examination (Part-2) NEW
NR 601 Week 4 Case Study Discussions Physical Examination (Part-1) NEW
NR 601 Week 4 Case Study Discussions Physical Examination (Part-2) NEW
NR 601 Week 5 Case Study Discussions Physical Examination (Part-1) NEW
NR 601 Week 5 Case Study Discussions Physical Examination (Part-2) NEW
NR 601 Week 6 Case Study Discussions Health Promotion, Health Protection, Disease Prevention, and Treatment Considerations in Long-Term Care (Part-1) NEW
NR 601 Week 6 Case Study Discussions Health Promotion, Health Protection, Disease Prevention, and Treatment Considerations in Long-Term Care (Part-2) NEW
NR 601 Week 7 Case Study Discussion Health Promotion, Health Protection, Disease Prevention, and Treatment Considerations in End-Of-Life Care (Part-1) NEW
NR 601 Week 7 Case Study Discussion Health Promotion, Health Protection, Disease Prevention, and Treatment Considerations in End-Of-Life Care (Part-2) NEW
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NR 601 Week 4 Case Study Discussions Physical Examination (Part-1) NEW
Discussion Part One (graded)
You are seeing S.F., a 74-year-old. Hispanic male in the office this morning for difficulty breathing.
Background:
S.F. presents with increased dyspnea on exertion that has become progressively worse over the last 3 days. You observe that he is using pursed lip breathing as he explains his chief complaint. He reports that he has been coughing up a moderate amount of thick, green sputum for approximately one week that was accompanied by a fever of 100.6 and chills. He took Ibuprofen 400 mg every 4 hours and increased his fluid intake for the last week. Two days ago he noticed that the sputum is now yellow rather than green and that he has not experienced any more fever. Overall, he feels like he is getting better. However, the dyspnea on exertion developed three days ago without relief despite the use of his Spiriva HandiHaler. He reports that he lost his rescue inhaler and has not had it to use in over 2 months.
PMH:
COPD
Hypertension
Osteoarthritis
Current medications:
Asprin-81 daily
Cyclobenzaprine 10 mg prn
Meloxicam 15 mg daily
Metoprolol 25 mg daily
Spiriva HandiHaler daily as directed
Tramadol 50 mg daily prn
Surgeries:
Appendectomy as a child (date unknown)
2004-Left cataract extraction with intraocular lens placement
2008-Right cataract extraction with intraocular lens placement
Allergies: NKA
Vaccination History:
Influenza vaccine- October 2013
Pneumovax-2010
His last TD-can’t remember
Has not a TDAP/TD in 20 years
Screening History:
Last Colonoscopy was 2012-normal
Last dilated retinal and glaucoma exam was 2013
Social history:
Retired roofer-stopped working in 2004 due to arthritis and pain in his rotator cuff. Is married and lives with spouse. They have 4 grown children who live within a 10 mile radius of them. Currently smokes-is down to ½ pack cigarettes daily. Has smoked for 45 years total.
Family history:
Father is deceased and had a history of hypertension and diabetes; Mother is deceased and had a history of CAD/MI; Sister-history of colon cancer.
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 2 Case Study Discussions Physical Examination (Part-2) NEW
Discussion Part Two (graded)
Physical examination:
Vital Signs
Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8 BP 110/70 T 98.0 po P 100 R 22, non-labored; Urinalysis: Protein 2+, Glucose: 4+
HEENT: normocephalic, symmetric. Bilateral cataracts; PERRLA, EOMI; Upper and lower dentures in place a fitting well. No tinnitus
NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. Thyroid non-palpable
LUNGS: Decreased breath sounds in bases bilaterally with rales, expiratory wheezing with prolonged expiratory phase noted throughout all lung fields. No costovertebral angle tenderness (CVAT) noted. Increase in AP diameter noted.
HEART: Irregularly irregular rhythm; Unable to detect S3 or murmur
ABDOMEN: Normal contour; active bowel sounds all four quadrants; no palpable masses.
PV: Pulses are 2+ in upper extremities and 1+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally;
NEUROLOGIC: Achilles reflexes are hypoactive bilaterally. Vibratory perception to the 128 Hz tuning fork placed at the MTP of her great toe is absent bilaterally; She is unable to discern monofilament placement in 3 locations on her left foot and 2 places on her right foot.
GENITOURINARY: no CVA tenderness; not examined
MUSCULOSKELETAL: Heberden’s nodes at the DIP joints of all fingers and crepitus of the bilateral knees on flexion and extension with tenderness to palpation medially at both knees. Kyphosis and gait slow, but steady.
PSYCH: normal affect; her Mini-Cog Score is 3. Her PHQ-9 score is 22.
SKIN: Sparse hair noted on lower legs and feet bilaterally with dry skin on her ankles and feet.
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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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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Link
http://www.uopassignments.com/nr-601-chamberlain-college-of-nursing/nr-601-week-4-case-study-discussions-physical-examination-part-1-recent
NR 601 Week 4 Case Study Discussions Physical Examination (Part-1) NEW
Discussion Part One (graded)
You are seeing S.F., a 74-year-old. Hispanic male in the office this morning for difficulty breathing.
Background:
S.F. presents with increased dyspnea on exertion that has become progressively worse over the last 3 days. You observe that he is using pursed lip breathing as he explains his chief complaint. He reports that he has been coughing up a moderate amount of thick, green sputum for approximately one week that was accompanied by a fever of 100.6 and chills. He took Ibuprofen 400 mg every 4 hours and increased his fluid intake for the last week. Two days ago he noticed that the sputum is now yellow rather than green and that he has not experienced any more fever. Overall, he feels like he is getting better. However, the dyspnea on exertion developed three days ago without relief despite the use of his Spiriva HandiHaler. He reports that he lost his rescue inhaler and has not had it to use in over 2 months.
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Link
http://www.uopassignments.com/nr-601-chamberlain-college-of-nursing/nr-601-week-2-case-study-discussions-part-2-recent
NR 601 Week 3 Case Study Discussions Physical Examination (Part-1) NEW
Discussion Part One (graded)
Katie Smith, a 65 year-old female of Irish descent, is being seen in your office for an annual physical exam. You are concerned since she has rescheduled her appointment three times after forgetting about it. She and her husband John are currently living with their daughter Mary, son-in-law Patrick, and their four children. She confesses that while she loves her family and appreciates her daughter’s hospitality, she misses having her own home. As she is telling you this, you notice that she develops tears in her eyes and does not make eye contact with you.
Background:
Although Mrs. Smith is scheduled for an annual physical exam and reports no particular chief complaint, you will need to complete a detailed geriatric assessment. Katie reports a lack of appetite. She tells you that she nibbles most of the time rather than eating full meals. She also reports having insomnia on a regular basis.
PMH:
Katie reports a recent bout of pneumonia approximately 3 months ago, but did not require hospitalization. She also has a history of HTN and high cholesterol.
Current medications:
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Link
http://www.uopassignments.com/nr-601-chamberlain-college-of-nursing/nr-601-week-1-case-study-discussions-physical-examination-part-2-recent
NR 601 Week 1 Case Study Discussions Physical Examination (Part 2) NEW
Discussion Part Two (graded)
Physical examination
Vital Signs:
Height: 5 feet 7 inches Weight: 170 pounds Waist Circumference – 32 inches BP 130/84 T 98.0 po P 92 regular R 22, non-labored
HEENT: normocephalic, symmetric. Evidence of prior cataract surgery in both eyes. PERRLA, EOMI, cerumen impaction bilateral ears. Several broken teeth, loose partial plate.
NECK: Neck supple; non-palpable lymph nodes; no carotid bruits.
LUNGS: Decreased breath sounds bases bilaterally, clear to auscultation
HEART: RRR with regular without S3, S4, murmurs or rubs.
ABDOMEN: Bloated appearance, active bowel sounds, LLQ tenderness and 6 cm x 7 cm mass.
PV: Pulses are 2+ BL in upper and lower extremities; no edema
NEUROLOGIC: Negative
GENITOURINARY: no CVA tenderness
MUSCULOSKELETAL: gait fluid and steady. No muscle atrophy or asymmetry. Full ROM all joints. Strength 5/5 and equal bilaterally.
Hips: Discomfort on flexion in both hips; extensor and flexor strength symmetrical.
Knees: Left knee discomfort with weight bearing. No redness, warmth or edema. Full ROM in both knees with symmetrical extensor and flexor strength. Crepitus on extension of left knee.
Hands: No redness or swelling. Bilateral joint tenderness of the distal interphalangeal and proximal interphalangeal joints of the 2nd and 3rd digits.
Calf circumference-31 cm; Mid-arm circumference- 22 cm
PSYCH: normal affect
SKIN: Pale. Areas of healing ecchymosis: Left knee- 3 cm x 2 cm x 0 cm. Right knee -2 cm x 2.5 cm x 0 cm.
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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Link
http://www.uopassignments.com/nr-601-chamberlain-college-of-nursing/nr-601-week-1-case-study-discussions-physical-examination-part-1-recent
NR 601 Week 1 Case Study Discussions Physical Examination(Part 1) NEW
Discussion Part One (graded)
You meet your first patient of the morning. A.K. is a 65-year-old Caucasian male who you are seeing for the first time. Both wife and daughter are present.
Background
He reports that he has had an 18-pound unintentional weight loss in the last 2 months “I am just not hungry anymore, and when I do eat, I get full so fast. In fact, it is really hard to eat, and I don’t eat nearly as much as usual, even though I eat 3 times every day”. He also reports feeling more tired than usual. “I am not sleeping very well. My wife wakes me up when I am snoring, or when she thinks I am not breathing. I used to have sleep apnea, but I don’t think I have it anymore. Besides, that mask is so horrible to wear.” He reports day time somnolence. He reports that he is at the clinic today because of his wife and daughter’s concern about his weight loss and loss of appetite.
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Link
http://www.uopassignments.com/nr-601-chamberlain-college-of-nursing/nr-601-week-4-case-study-discussions-physical-examination-part-1-recent
NR 601 Week 4 Case Study Discussions Physical Examination (Part-1) NEW
Discussion Part One (graded)
You are seeing S.F., a 74-year-old. Hispanic male in the office this morning for difficulty breathing.
Background:
S.F. presents with increased dyspnea on exertion that has become progressively worse over the last 3 days. You observe that he is using pursed lip breathing as he explains his chief complaint. He reports that he has been coughing up a moderate amount of thick, green sputum for approximately one week that was accompanied by a fever of 100.6 and chills. He took Ibuprofen 400 mg every 4 hours and increased his fluid intake for the last week. Two days ago he noticed that the sputum is now yellow rather than green and that he has not experienced any more fever. Overall, he feels like he is getting better. However, the dyspnea on exertion developed three days ago without relief despite the use of his Spiriva HandiHaler. He reports that he lost his rescue inhaler and has not had it to use in over 2 months.
0 notes
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