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Module 1: Discussion

3. Mr. B is a 70-year-old man who developed sub sternal
chest pains radiating down his left arm while at home. He was taken to the ER via
ambulance. His breathing was labored, pulses rapid and weak, and his skin was
cold and clammy.An ECG was done which revealed significant “Q” waves in most
leads. Troponin level was elevated. Arterial blood was draw with the following
results:

Ph 7.22

PCO2 30 mm

Hg pO2 70 mm

Hg O2 sat 88%

HCO3 22 meq/liter

1. Aside from the obvious diagnosis of MI, what is Mr. B’s
acid base status and what caused this disturbance?

Module 2: Discussion

Melissa, a 12-year-old girl with cystic fibrosis comes to
the primary care office with complaints of increased cough and productive green
sputum over the last week. She also complains of increasing shortness of
breath. She denies sore throat or nasal congestion. On physical examination her
temperature is 101 and she has inspiratory wheezes bilaterally. Negative
lymphadenopathy noted. Posterior pharynx is pink without exudate. BP 112/72 HR
96 RR 28.

1. In cystic fibrosis, the airway microenvironment favors
bacterial colonization. In a minimum of 150 words explain the
pathophysiological reason for this occurrence.

Module 3: Discussion

Mr. B, a 40-year-old avid long-distance runner previously in
good health, presented to his primary provider for a yearly physical
examination, during which a suspicious-looking mole was noticed on the back of
his left arm, just proximal to the elbow. He reported that he has had that mole
for several years, but thinks that it may have gotten larger over the past two
years. Mr. B reported that he has noticed itchiness in the area of this mole
over the past few weeks. He had multiple other moles on his back, arms, and
legs, none of which looked suspicious. Upon further questioning, Mr. B reported
that his aunt died in her late forties of skin cancer, but he knew no other
details about her illness. The patient is a computer programmer who spends most
of the work week indoors. On weekends, however, he typically goes for a 5-mile
run and spends much of his afternoons gardening. He has a light complexion,
blonde hair, and reports that he sunburns easily but uses protective sunscreen
only sporadically.

Physical exam revealed: Head, neck, thorax, and abdominal
exams were normal, with the exception of a hard, enlarged, non-tender mass felt
in the left axillary region. In addition, a 1.6 x 2.8 cm mole was noted on the
dorsal upper left arm. The lesion had an appearance suggestive of a melanoma.
It was surgically excised with 3 mm margins using a local anesthetic and sent
to the pathology laboratory for histologic analysis. The biopsy came back Stage
II melanoma.

1. How is Stage II melanoma treated and according to the
research how effective is this treatment?

Module 4: Discussion

Mrs. K is a 60-year-old white female who presented to the ER
with complaints of her heart “beating out of my chest.” She is complaining that
she is having increased episodes of shortness of breath over the last month and
in fact has to sleep on 4 pillows. She also notes that the typical swelling
she’s had in her ankles for years has started to get worse over the past two
months, making it especially difficult to get her shoes on toward the end of
the day. In the past week, she’s been experiencing fatigue and decreased urine
output. Her past history is positive for an acute anterior wall myocardial
infarction and coronary artery bypass surgery. She was a 2 pack a day smoker,
but quit 8 years ago.

On physical examination, auscultation of the heart revealed
a rumbling S3 gallop and inspiratory crackles. She has +3 edema of the lower
extremities.

1. Discuss the pathophysiology of an S3 heart sound and
include causes for an S3 gallop?

Module 5: Discussion

Brian is a 7-year-old boy who presents to the primary care
office with his mother. His mom has noticed that Brian has been coughing
frequently and seems to have shortness of breath at times. She reports that
Brian had a “cold” with a low grade fever and runny nose about 2 weeks ago and
the symptoms seem to appear after the cold.

On physical examination, Brian appears in moderate
respiratory distress, with suprasternal and intercostal retractions. His vital
signs include a temperature of 100 A°F, a respiratory rate of 32 breaths per
minute, heart rate of 120 beats per minute, and pulse oximetry of 95% on room
air. Lung exam is notable for diffuse symmetrical expiratory wheezes. His nasal
mucosa is erythematous with boggy turbinates and clear mucus. The remainder of
the exam is unremarkable.

1. Based on this case, discuss the differences in the
pathophysiology for asthma vs
pneumonia. Include your thougths as to
the diagnosis for this case.

Module 6: Discussion

Mike is a 23-year-old white male admitted for severe
depression. He has a history of bipolar disorder and is currently taking
valproate (Depakote) 500 mg XR daily. His psychiatrist ordered LFT’s to follow
the valproate therapy. LFT’s were abnormal: ALT 1178 u/L, AST 746 u/L. the
patient was asymptomatic. He denies fever, abdominal pain, nausea, vomiting or
jaundice. He denies using other medication or alcohol but admits using illicit
IV drugs starting about 8 weeks ago and continuing to present. He never had a
blood transfusion. Aside from Depakote he is presently taking clonazepam 1 mg
prn and fluoxetine (Prozac) 40 mg qd.

Other blood work: Direct bili 1 mg/dL, alkphos 188 u/L,
anti-HCV negative on hospital day 1, positive on day 3. HCV-RNA PCR positive.
Hep A, B, and D markers negative.

Patient diagnosis: Acute Hepatitis C.

1. List some clinical manifestations typically seen in
Hepatitis C and major treatment strategies.

Module 7: Discussion

A nurse practitioner (NP) is talking with a 70-year-old
patient who asks if she could discuss a problem that she is embarrassed to talk
about with her physician. She states she has been having increasing problems
with incontinence. Every time she coughs or sneezes, she notices a loss of
urine. She has not had any fever or chills or pain with urination. She asks the
NP if this is just a sign of getting older?

1. Discuss the etiology associated with incontinence in the
aging adult.

Module 8: Discussion

Ann is a 32-year-old married female who presents to her
nurse practitioner reporting lower abdominal pain, cramping, slight fever, and
dysuria of 3 days duration.

History includes:

LMP 2 weeks ago (regular)

Reports oral contraceptive use

Reports pain in lower abdomen with cramping and pain on
urination for 3 days

Denies any GI problems, reports regular bowel movements.

Denies vaginal discharge

Ann is married and in a monogamous relationship. Has one
child age 2

Reports no use of condoms/sexual intercourse 2-3 times per
week

Denies any history of STDs

Physical Exam reveals:

Temp 100.6, P 80 BP 100/62 Wt. 125 Ht. 5’3’’

HEENT WNL

No CVA tenderness

Pain in lower quadrants with light palpation.Positive
inguinal lymphadenopathy

External genitalia without lesions or discharge

Pelvic exam reveals minimal cervical mucopus

Bimanual exam reveals uterine and adnexal tenderness and
cervical motion pain. Uterus anterior, midline, smooth, not enlarged

1. Based on the above case the diagnosis is PID, What is an appropriate CDC-recommended
therapeutic regimen for this patient?

Module 9: Discussion

A 38-year-old African-American woman was admitted for
arthroscopic knee surgery. Her hematocrit was 25%, blood pressure was 140/94 mm
Hg, and pulse was 112 beats/minute. She had a history of joint and bone pain,
jaundice, and abdominal pain.

Due to the presenting symptoms (joint and bone pain,
abdominal pain, and jaundice) a diagnosis of Sickle Cell Disease was
considered.

1. Provide a brief discussion of the pathophysiology of
sickle cell disease and discuss the clinical manifestations and the etiology
associated with each manifestation of this disease.

Module 10: Discussion

A 28-year-old male presents to the primary care office for
evaluation of left calf pain, swelling, and redness. He reports that this
started one day ago and worsened today. He ran a 27-mile marathon 2 days ago
and traveled for 3 hours in a car today. He reports slight pain on walking and
a swollen red calf. He took Ibuprofen 600 mg twice today without relief.
Patient reports being an experienced runner, running 3-5 miles daily. He
trained for the marathon for 4 months. Patient also reports a history of
exercise induced asthma and uses albuterol sulfate HFA as needed.

On physical exam patient appears in good health T 99 P 68 R
18 BP 118/78 wt. 175 lb, height 72 in. BMI 23.1. Heart rate is regular without
murmurs, rubs, or gallops. Lungs clear bilaterally. HEENT WNL.Strength lower
extremities +5 and DTRs + 2.Left calf erythematous, edematous, warm and tender
on palpation.Pulses 3+.

Two possible diagnoses were considered: deep vein thrombosis
(DVT) and rhabdomyolysis.

Stat ultrasound of left leg to rule out DVT was ordered and
read as normal

CBC WNL

Creatine Kinase (CK) 23,000 U/L (normal 24-170 U/L)

BUN and Creatinine WNL

A diagnosis of rhabdomyolysis was made.

1. Discuss the pathophysiology
of acute renal failure in rhabdomyolysis.

Module 11: Discussion

Bob, a 38 year old male, has been experiencing severe
intermittent headaches for about 10 years. When they occur, he experiences
intense burning pain on one side of his head, tearing in his eye, congestion
and a runny nose. These headaches generally occur several times a day and last
approximately one hour. The headaches are episodic; Bob can be headache free
for several months but then experience an attack.

1. Based on the case scenario, provide a diagnosis for Bob.
Provide the pathophysiology for this type of headache and discuss current
treatment options.

Module 12: Discussion

How will your clinical practice improve with the integration
of the course content?

In a minimum of 150 words, provide a main discussion to the
questions above by Wednesday at midnight.
Respond to one of your classmates on a separate day of the week from
your original posting.

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