NURS663B Primary Care Adult and Geriatric Patient Theory
Week 1 Forum
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #1, 45-year-old woman, intermittent fevers.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
In your peer replies, please reply to at least one peer who chose a different case study.
Case Studies
1. A 45-year-old woman is seen in the office with a chief complaint of a 3-month history of “intermittent fevers,” sweating, and flushing. She describes these “fevers” as “feeling like a furnace on the inside from the mid-chest to the top of my head.” She says she turns “beet red” and starts to sweat. These episodes only last a few minutes but occur throughout the day and wake her up several times at night. Her medical history is unremarkable. She reports that her menstrual cycles have been regular her entire life but are now irregular; her last menstrual period was about 3 months ago. She takes no prescription medications. Her last annual exam with Pap test was 2 years ago.
2. A 35-year-old woman is seen in the office with a chief complaint of a breast mass. She states she found the lump when she was in the shower, and she is quite visibly distressed. Her medical history is unremarkable, although she reports that she has not had a mammogram. She takes no prescription medications.
3. JoAnne is a 29-year-old who comes to the clinic with 3 days of foul vaginal odor and moderate yellowish vaginal discharge. She is sexually active and occasionally uses condoms with her new partner. She does not use any other form of birth control.
NURS663B Primary Care Adult and Geriatric Patient Theory
Week 2 Forum
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #1 45-year-old woman, intermittent fevers.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
In your peer replies, please reply to at least one peer who chose a different case study.
Case Studies
1. Susan is a 30-year-old registered nurse who works in transitional care. She presents to employee health stating, “My back is killing me. I was helping to transfer a patient and he moved. I thought he was going to fall, so I twisted around to grab onto him and wrenched my back. The pain is terrible, and I can barely walk." Susan is a healthy young adult, married with a 5-year old. daughter. She has no significant family history. Susan has a past medical history of fractured coccyx as a teenager when she fell during cheerleading practice; no sequelae. She has smoked one-half pack of cigarettes a day since age 15 but is trying to quit. Current medicines include medroxyprogesterone acetate (Depo Provera) injection for birth control every 13 weeks. She is supposed to take calcium, but states that she "always forgets, and it constipates me anyway.” Susan denies any change in bowel/bladder habits.
2. Mary is a 70-year-old widow with a history of osteoarthritis. She has been self-medicating with over-the-counter acetaminophen, either extra strength (500 mg/tablet) or arthritis strength (650mg/tablet) for over a year now. In addition to osteoarthritis, she also has osteoporosis and gastroesophageal reflux. She presents with the complaint of backache and right knee pain, aggravated by climbing stairs. She describes her knee pain as 8 on a scale of 1 to 10: “I can stand the back pain, but the knee is awful.” She lives alone but has two supportive daughters nearby. They take her shopping and help with housework. On good days, she goes to the senior center for lunch and socialization. She was doing exercises at the Senior Center but stopped due to her knee pain. She does not smoke or drink alcohol, except at birthday parties and celebrations. She denies any medication, food, or environmental allergies. In addition to the acetaminophen, medications include calcium with vitamin D, Protonix (pantoprazole), and an annual intravenous infusion of Reclast (zoledronic acid). She also has been taking a dietary supplement of glucosamine/chondroitin for 3 months. She recently had a complete physical examination with electrocardiogram and laboratory tests and was told that everything was “normal.”
3. Linda is a 45-year-old female who returns to the office four weeks after a slip and fall at home. Initially, she had some mild-to-moderate soreness that was alleviated with heat and occasional Aleve. She now presents with pain across her lower back, pain with sitting and standing, and radiation of pain and numbness through her right buttock and down through her right thigh. She is taking Aleve twice daily and Tylenol every eight hours with moderate relief of pain, but it doesn't help with the numbness. The pain wakes her at night. There has been no change in her bladder or bowel habits.
NURS663B Primary Care Adult and Geriatric Patient Theory
Week 3 Forum
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #1 45-year-old woman, intermittent fevers.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
In your peer replies, please reply to at least one peer who chose a different case study.
Case Studies
1. K is a 42-year-old female who runs marathons 3 to 4 times a year and maintains a very active lifestyle. She complains of decreased energy levels for the past 4 to 6 months with a six pound weight gain over the past six months and she has noted some hair loss in the shower. She states that she is sleeping well, but does not feel refreshed in the morning.
2. A 32-year-old obese female presents with complaints of a vaginal infection and nocturia for the past two weeks. She said she has used over-the-counter treatment for the vaginal infection, but it keeps coming back. She states that she is always thirsty and cannot get any rest because she has to get up to use the bathroom three to four times a night.
3. A 54-year-old male presents with pain to both feet, with swelling to his right big toe. He has a temperature of 100, and also complains of hand pain. The patient states that he has had pain in his feet before. His wife usually gives him ginger tea, and it goes away in a day or two, but it hasn’t helped this time. Your assessment demonstrates a tender and swollen right first MTP with redness and pain throughout the midfoot. There is also pain to the left midfoot. The patient also has a history of essential hypertension and takes HCTZ 25mg daily.
NURS663B Primary Care Adult and Geriatric Patient Theory
Week 4 Forum
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #1 45-year-old woman, intermittent fevers.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
In your peer replies, please reply to at least one peer who chose a different case study.
Case Studies
1. Jenny G., a 48-year-old recovering intravenous (IV) drug abuser, presents with general malaise, anorexia, abdominal pain, and slight jaundice. She is currently staying in a women’s shelter and is looking for a job. She is divorced with two grown children whom she hasn’t been in contact with for years. She returns to your office for her lab results. You note that her ALT is elevated, and that her Hepatitis A and C antibodies are positive.
2. Mrs. J., age 42, has been married for 20 years to a high school teacher. She has 16-year-old twins who are in high school. She is coming in for a routine physical, because she said over the phone that she has no energy and has lost some weight. She also thinks she has had a temperature for several days. She has the following physical exam findings: temperature, 101°F; weight loss of 10 lbs. since her previous visit last year; flu-like symptoms; nonproductive cough; bilateral lymphadenopathy in cervical and supraclavicular nodes; and decreased breath sounds in bilateral bases.
3. Michael, a 33-year-old realtor, comes to your offices with a severe rash that he has had for the past two days that started on his stomach and has now spread to his arms and trunk, and is spreading to his face. He denies shortness of breath, but states that his lips and throat feels itchy. He took several doses of Benadryl without any relief. He denies any new foods or medications or environmental exposures. On examination you notice diffuse, generalized urticarial rash. Vital signs are stable.
NURS663B Primary Care Adult and Geriatric Patient Theory
Week 5 Forum
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #1 45-year-old woman, intermittent fevers.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
In your peer replies, please reply to at least one peer who chose a different case study.
Case Studies
1. Mildred is a 45-year-old married female with three children. She presents to you with complaints of fatigue and difficulty sleeping. She states she wants to get a good night’s sleep and is requesting a prescription to help her sleep. Mildred tells you she is awake off and on during the night, frequently thinking about her husband’s recent layoff from construction work and the effect this is having on the family. She lies down often during the day and has been so fatigued that she took some time off from work during the last two weeks. She is tearful at times during the visit and looks sad and anxious. On further discussion, she says she feels overwhelmed, helpless, and anxious. She tells you about an episode where she felt her heart beating rapidly, had difficulty catching her breath, felt she was going to have a heart attack, and became frightened until her husband was able to help calm her down. She is not eating as much as usual, and when she reads the newspaper, she does not remember what she has read.
2. Kylie, a 24-year-old female patient, comes to your office for a refill of her allergy medication. Before going into the room, you note that her Patient Health Questionnaire – Depression (PHQ-9) score is 20, and that she is not currently on any medication for depression. When you enter the room, you notice that Kylie is easily startled, and she is sitting in the corner of the room very close to the wall.
3. Dale, a 40-year-old construction worker, lost his 4-year-old daughter in a car accident six months ago, in which his sister was driving and he was a passenger. He is at this visit for a follow-up of a shoulder injury sustained last month. You notice that he has lost about eight pounds since his last visit, and he is somewhat disheveled in his appearance. Dale has not been back to work, and has not been able to get into a car since the accident. Before going into the room, your nurse pulled you aside to let you know that the patient was very rude to the front office staff, and was also rude to her while he was being processed for his visit. This is not Dale’s usual behavior.
NURS663B Primary Care Adult and Geriatric Patient Theory
Week 6 Forum
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #1 45-year-old woman, intermittent fevers.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
In your peer replies, please reply to at least one peer who chose a different case study.
Case Studies
1. Carl, a 56-year-old male, was hanging lights around his house today on a ladder when he turned sharply to catch a bulb and felt a sharp pull in his lower back. He presents to the clinic with a compensated gait, and is unable to sit due to discomfort. His vital signs are stable, and he has no medical history other than occasional allergies.
2. David, a 36-year-old male, presents to the clinic after an altercation last night in which he was in a fight after an evening of drinking heavily. He reports to you that he remembers punching another person in the mouth and cutting his hand, and also hitting a wall with the same hand. You notice that he also has several cuts on his lip and an abrasion over his eye. He is accompanied by his girlfriend who agrees with David’s account of the story, and denies any loss of consciousness or head injury. The patient returns from X-ray, with a report of a fracture to 2nd and 3rd MCP, or “boxer’s fractures,” to the right hand. He also has several lacerations over his knuckles that are jagged, and are most likely from teeth.
3. Anna is a 72-year-old diabetic patient on Metformin 1000mg twice daily who was bitten several times on her hands and legs by a neighborhood cat that she was feeding last night. She also received several scratches to her face and mouth, and she has several puncture marks to her hands.
NURS663B Primary Care Adult and Geriatric Patient Theory
Week 7 Forum
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #1 45-year-old woman, intermittent fevers.
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
In your peer replies, please reply to at least one peer who chose a different case study.
Case Studies
1. Julie is a 26-year-old hockey coach who was violently hit into the end boards about two weeks ago and was removed from the ice on a stretcher. Her head CT was clear and neck X-rays were negative. She presents today for 8 out of 10 lower back pain that is not responsive to Motrin. She has no radicular symptoms and no other past medical history.
2. Mark is a 46-year-old firefighter on disability for the past year due to a 30" fall from a ladder in which he sustained a pelvic fracture, a left femur fracture, and several disc fractures to his spine. He has been on Norco, one pill every six hours for the past year, although sometimes he does not take the medication at all. Today, he presents to the clinic for escalating pain over the past week, with no relief from Norco. His symptoms include numbness to both feet, numbness to his tailbone, and sharp pain throughout his lower back. He denies any new trauma.
3. Cleo is a 55-year-old who was diagnosed with fibromyalgia three years ago. She has been treating her muscle pain with stretching and has been taking Prozac for about two years, which has stabilized her sleep pattern and helped with pain. Her pain has worsened significantly in the past four to five months, interfering with her ADLs, exercise routine, and mood. Today, she has ten positive trigger points and a severe migraine for which she has already taken two doses of Imitrex without relief. She is extremely teary and feeling hopeless. She tells you that she does not want to become one of those “fibromyalgia patients that everyone makes fun of.”
NURS663B Primary Care Adult and Geriatric Patient Theory
Week 8 Forum
Please respond to one of the following discussion prompts. In the subject line of your post, please identify which prompt you are responding to, for example, #2 compassion fatigue.
1. Self-care is important to personal health, professional growth, and the ability to care for others. Discuss the importance of self-care for the APRN. Provide examples with your rationale.
2. Compassion fatigue is flourishing in our society today, due in part to the increasing demands of managed care, and it can impair your ability to function effectively. Discuss strategies to avoid compassion fatigue. Provide examples with your rationale.
