nr601 all week discussions

Week 1 discussion

PART 1

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.

PART 2

Discussion Part Two

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.

Week 2 discussion

PART 1

B.J., a 70-year-old black female has been seen in the clinic
several times. The last time she was in for a check-up was 6 months ago to get
her prescriptions refilled. She has returned to the clinic today because she
“ran out of blood pressure medicine” and would like to get her prescriptions
renewed. She has not taken any prescription medicine in approximately 6 months

Background:

The patient indicates that she has noticed shortness of
breath, especially when she is playing with her grandchildren. But, it goes
away once she sits down to rest. She reports that she is also bothered by
shortness of breath that wakes her up at night, but it resolves after sitting
upright on 3 pillows. She also tells you
that “I noticed over the last week that my legs and ankles have been swollen”.
She also indicates that she often feels light headed and faint while going up
the stairs, but it subsides after sitting down to rest.

PMH:

Hypertension

Previous history of MI in 2010

Current medications:

Coreg 6.25
mg PO BID

Colace 100
mg PO BID

K-dur 20
mEq PO QD

Furosemide
40 mg PO QD

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:

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%, K+ 4.2,

Na+140 Cholesterol 186, Triglycerides 188, HDL 37, LDL 190,
TSH 3.7

Blood pressure on day of visit: 150/90

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 son lives
in another state,

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:

She drinks one 4-ounce glass of red wine daily. She is a
former smoker that stopped 20 years ago.

Discussion Part One:

Summarize the important data from the patient’s history and
reason for the visit today.

Provide differential diagnoses (DD) with rationale.

Further ROS questions needed to develop DD.

Based on the LDL level above, indicate if you need to order
a statin for this patient? Provide a rationale for your decision based on
evidence based clinical guidelines.

What other patient risk factors put the patient at risk for
arteriosclerotic coronary vascular disease (ASCVD)?

·
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.

PART 2

Patient Information

B.J., 70 y/o, Female, African-American

Week 3 discussion

PART 1

Mr. M.J. is a 64-year-old patient of Hispanic descent who
presents to the clinic today with concerns about epigastric and substernal pain
that has gotten progressively worse over the past 3 months. He complains of
mild “heartburn after eating a large meal for at least 2 years. He has tried
over the counter products occasionally with adequate response. Three months
ago, he was awakened with severe burning discomfort that extended from his
mid-chest to his jaw that lasted 30 minutes before he was able to fall back to
sleep. He is now experiencing these attacks about 3 times per week. He has
tried avoiding large meals and is now sleeping on two pillows at night to
relieve his pain which has improved his pain. The pain now occurs regularly
after meals and randomly during the day. He takes antacids with each meal, but
the pain still persists. Overall, he considers himself to be very healthy.

Past Medical History

Depression diagnosed 6 months ago

Family History

Unknown; was adopted from an orphanage when he was 3 months
old; Wife died of breast cancer approximately 8 months ago. They were unable to
have children.

Social History

Drinks beer occasionally when out with friends

No smoking history

Current Medications

Multivitamin daily

Discussion Questions Part One

Describe how you would work-up this patient’s abdominal pain
based on current clinical guidelines.

Provide further ROS questions needed to develop differential
diagnoses.

Provide the differential diagnoses (DD) with rationale.

Decide whether or not this patient should also be worked-up
for depression. Why or why not?

Based on the data provided, what types of screening tools
would be useful in this patient’s case?

PART 2

S. (Subjective)

CC – Mild “heartburn” after eating a large meal for at least
2 years.

Background: Mr. M.J. is a 64-year-old patient of Hispanic
descent who presents to the clinic today with concerns about epigastric and
substernal pain that has gotten progressively worse over the past 3 months. He
has tried over the counter products occasionally with adequate response. Three
months ago, he was awakened with severe burning discomfort that extended from
his mid-chest to his jaw that lasted 30 minutes before he was able to fall back
to sleep. He is now experiencing these attacks about 3 times per week. He has
tried avoiding large meals and is now sleeping on two pillows at night to
relieve his pain which has improved his pain. The pain now occurs regularly
after meals and randomly during the day. He takes antacids with each meal, but
the pain still persists. Overall, he considers himself to be very healthy.

HPI:

Current Medications:

PMH:

Social Hx:

Family Hx

Focused ROS and Physical Exam:

ROS:

Objective:

Physical examination:

Primary Diagnosis:

Differential Diagnosis:

Plan:

Week 4 discussion

PART 1

Mrs. R. is a 66-year-old Caucasian female who presents to
the clinic with pain in her left hip that worsens with walking, bending,
standing, and squatting. When asked to describe where the pain occurs, she
places her fingers around the anterolateral hip region. She denies any back
pain, or pain in the posterior hip or along the lateral thigh. Denies any
previous injury, stumbling, tripping or falling. She states that the pain has
been getting gradually worse and is almost constant if she walks or stands for
a long period of time. She denies back pain, numbness, tingling, or weakness in
the extremities. She reports taking Ibuprofen 800 mg approximately 3 times/week
whenever she has significant hip pain. She is concerned that she doesn’t know
what is causing the pain and that she is having to take increased doses of
ibuprofen to manage the pain. She reports a current pain level of 8/10 on the
pain scale.

Background Information

She walks approximately 1 mile a day. She recently retired
as an office manager 4 years ago.

PMH

Unremarkable

Immunizations

All vaccines are current

Screenings

Never had a colonoscopy

Last mammogram was 5 years ago

Social History

Has an occasional glass of wine with dinner

Does not smoke

Surgical history

Cholecystectomy 20 years ago

Hysterectomy 10 years ago

Current Medications

Ibuprofen 200-800 mg prn for hip pain

Discussion Questions Part One

What risk factors does this patient have that might
contribute to her hip pain?

What ROS would you conduct on this patient?

What is your primary diagnosis? What evidence-based resource
and patient data supports this diagnosis?

What two differential diagnoses are appropriate in this
patient’s case? What evidence-based resource and patient data supports these
two differential diagnoses?

What screening would you choose to best evaluate this
patient’s chief complaint?

PART 2

Physical Exam:

Vital signs: blood pressure 128/84, heart rate 80
respirations 20, temperature 98.5

height 5’3”, weight 130 pounds

General: no acute distress

HEENT: Head normocephalic without evidence of masses or
trauma. PERRLA, EOMs intact. Noninjected. Fundoscopic exam unremarkable. Ear
canal without redness or irritation, TMs clear, pearly, bony landmarks visible.
No discharge, no pain noted. Neck negative for masses. No thyromegaly. No JVD
distention

Skin: intact

CV: S1 and S2 RRR, no murmurs, no rubs

Lungs: Clear to auscultation

Abdomen: Soft, nontender, nondistended, bowel sounds present
all 4 quadrants, no organomegaly, and no bruits

Musculoskeletal: No pain to palpation; Antalgic gait noted
when patient rises from seated position to standing and begins to walk. Active
and passive ROM decreased with stiffness

Neuro: Sensation intact to bilateral upper and lower
extremities; Bilateral UE/LE strength 5/5.

Discussion Questions Part Two

For the primary diagnosis explain how you would proceed with
your work-up and include the following: lab work and imaging studies

How would you manage this patient pharmacologically? Is it
appropriate that she is taking Ibuprofen prn?

What non-pharmacological strategies would be appropriate?

Describe patient education strategies.

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

Week 5 discussion

PART 1

Mr. K. is a 70-year-old Native American male who presents
with complaints of nocturia. He indicates that he has been waking up to urinate
more than 3 times each night. In addition, he reports having urinary frequency
during the day, starting and stopping a stream, and doesn’t feel like his
bladder is completely empty after urination. He denies any pain on urination,
fever or chills. His last PSA 2 years
ago was negative.

PMH: arthritis in both knees; takes over the counter ibuprofen
as needed for joint pain.

Social history: non-smoker; drinks 2-3 beers on the weekend

Discussion Questions Part One

What additional assessments/diagnostic tests might be
helpful in the work-up? (patient’s chief complaint)

Conduct a ROS on this patient.

List your differential diagnoses.

Share at least one tool that could be used to assess the
severity of urinary symptoms in men.

What primary diagnosis are you choosing at this point?

PART 2

Physical Exam:

Discussion Part Two (graded)

Vital signs: blood pressure 140/80, heart rate 76, respirations
16, temperature 98.0;

weight 210 pounds; height 5’9”

General: no distress; no weakness or fatigue

HEENT: unremarkable

Heart: S1 and S2 RRR; no murmurs, gallops or rubs

Lungs: breath sounds clear throughout lung fields

Abdomen: soft, nontender with positive bowel sounds all 4
quadrants

GU: negative CVA tenderness

Rectal: digital rectal exam reveals enlarged prostate that
is smooth and nontender

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

Include the following: lab work and imaging studies

Describe patient education strategies.

Describe follow-up.

Describe any referrals that may be necessary.

Week 6 discussion

PART 1

Ms. S. is a 62-year-old black female who has returned to the
clinic to discuss her concerns that her lifestyle modifications to lose weight
have not worked. At the last visit 3 months ago, she was advised to change her
eating habits and increase activity to promote weight loss. She reports walking
at least 30 minutes a day but has lost very little weight. She indicates that
the walking only made her extremely thirsty and hungry and attributes her
increased thirst and hunger to increased exercise and her increased urination
due to drinking more water since “it’s been hot lately” and exercise makes me
thirsty”. She has returned to the clinic to discuss if there is anything else
that can be done to lose weight and to determine why she is so tired, thirsty
and hungry all the time. She also thinks she may have an overactive bladder
since she has to urinate frequently during the day, which has influenced her
not to go on outings with her friends.

Discussion Questions Part One

Conduct a ROS on this patient.

Indicate which symptoms are most concerning to you.

List your differential diagnoses.

What types of screenings would be appropriate to use based
on the chief complaint?

What primary diagnosis are you choosing at this point?

PART 2

Physical Exam:

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.

Week 7 discussion

PART 1

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.

PART 2

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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