NR 601 Week 2 Case Study Discussions Physical Examination (Part-2) NEW
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 5 Case Study Discussions Physical Examination (Part-1) NEW
Discussion Part One (graded)
C.W. is a tall, thin 78-year-old African American male brought into the office by his son who states that the patient is restless, angry, and has been unable to sleep for the last week. The son indicates that he is very concerned about his father because he lives alone. Also, he is concerned about the “strange” symptoms that his father has presented with recently.
Background:
C.W. presents as restless, hyperverbal, obnoxious and angry. He expresses himself by periodic yelling. He is unkempt and smells strongly of urine, alcohol and body odor. ………… has an unsteady gait and sways while standing. As you converse with the son, you determine that C.W. was medically separated from military service due to mental health issues after 2 years of active duty that ended in 1947. He has been married and divorced three times over the years. He typically seeks no acute or preventative medical care. ___ was treated by a psychiatrist previously, but he did not like taking the prescribed medications so he stopped taking them and did not keep any further psychiatric appointments.
PMH:
Patient denies any previous diagnoses. However, when asked why he saw a psychiatrist in the past, he tells you that the psychiatrist diagnosed paranoid schizophrenia, but that he does not have any psychiatric diagnoses or problems. He states: “It was just a way for him to make money off me coming in and seeing him and paying the drug companies for me to take all those meds!”
Current medications:
Denies prescription medications, over the counter medication, herbal therapies or vitamins.
Surgeries:
Denies surgeries
Allergies: NKA
Vaccination History:
Flu vaccine: never given
Pneumovax: never given
Tetanus: never given
Herpes zoster: never given
Screening History:
Last Colonoscopy was 2012-normal
Last dilated retinal and glaucoma exam was 2013
Social history and Risk Factors:
Patient admits to smoking cigarettes and cigars. …… estimates that he smokes about 1 pack of cigarettes daily for the last 40 years, and 2 cigars each week for the last 30 years.
He states that he drinks a 24 ounce bottle of beer 4-6 times a week. … denies drinking wine or hard liquor. …….. does admit to smoking marijuana on occasion but does not use other recreational drugs. Patient denies falling. You notice some scrapes on his forearms, and when asked, he tells you that he fell yesterday: “I got pretty drunk out fishin’ with friends and fell off my bike trying to ride home”. He does not use any assistive devices for ambulation or balance.
Significant ROS:
Productive cough with white sputum. Denies hemoptysis.
He answers “No” to the PHQ-2 screening questions.
Family history:
Reports no significant family history
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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PSY 490 Week 1 Summary
PSY 490 Week 1 Summary
Write and present a summary of how this week’s readings and activities have affected your thought process regarding any aspect of this week’s Capstone course. (350 – 500 Words)
PSY 490 Week 2 Summary
Write and present a summary of how this week’s readings and activities have affected your thought process regarding any aspect of this week’s Capstone course. (300 – 500 Words)
PSY 490 Week 3 DQ 1
The Ethics Awareness Inventory CORE concepts do not include Kohlberg’s stages of moral development. Why do you think that is? Do you think they concur? Explain your responses.
PSY 490 Week 3 DQ 2
What are the advantages or disadvantages of a psychology degree? What are the advantages or disadvantages of a bachelor’s, master’s, and doctorate degree in psychology?
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PSY 490 Week 1 DQ 2
How is the field of psychology similar to other sciences? How is it different? Do you believe that psychology should be classified as a science? Why or why not?
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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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