NR601 Week 1 Discussion Part 1 & 2 Latest

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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.

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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. NR601 Week 1 Discussion Part 1 & 2 Latest

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. NR601 Week 1 Discussion Part 1 & 2 Latest

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.

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. NR601 Week 1 Discussion Part 1 & 2 Latest

Habits:

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

Discussion Part One: NR601 Week 2 Discussion Case Study Assignment

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

Chief complaint: medication refill “ran out of medicine”

HPI: BJ, a 68-year-old AA female presents to the clinic for prescription refills. The patient also indicates that she has noticed shortness of breath which started about 3 months ago. The SOB gets worse with activity, 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 has lower leg edema which started 1 week ago. She also indicates that she often feels light headed and faint while going up the stairs, but it subsides after sitting down to rest. She has not tried any OTC medications at home. She never filled her prescriptions, which she received at her checkup 6 months ago, she did not think it was important.

PMH:

Hypertension

Previous history of MI in 2010

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

Social history:

High school graduate, a widow with one son who loves out of state. She drinks one 4-ounce glass of red wine daily. She is a former smoker that stopped 20 years ago.

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.

ROS:

Constitutional: Lightheaded and faint with exertion.

Respiratory: Shortness of breath with exertion (playing with grandchildren and stairs). + Orthopnea

Cardiovascular: + leg and ankle swelling x 1 week

Psychiatric: Not taking medications for 6 months – “ran out”

Physical examination:

Vital Signs

Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8 BP 150/86 T 98.0 oral P 100 R 22, non-labored;

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: inspiratory crackles

HEART: Normal S1 with S2 split during expiration. An S4 is noted at the apex; systolic murmur noted at the right upper sternal border without radiation to the carotids.

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

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.

Labs:: Hgb 12.2, Hct 37%, K+ 4.2, Na+140, Cholesterol 230, Triglycerides 188, HDL 37, LDL 190, TSH 3.7, glucose 98 BUN 12 Cr 0.8

Primary Diagnosis:

Congestive Heart Failure (CHF) (150.9)

Secondary Diagnoses:

Primary Hypertension (I10)

Depression F32.3:

Obesity (E66):

Osteoarthritis (OA) (715.90)

Differential Diagnosis:

Peripheral Vascular Disease (PVD) (173.9)

Medications:

Sertraline 25 mg. Take 1 tab PO QD disp#30, 1 refill

Tylenol 650 mg PO Q4 hours as needed for arthritis pain

Labs: UA; Brain natriuretic peptide (BNP); LFTs and TSH.

12-lead EKG, Chest X-ray; Initial 2D echo with Doppler; Ankle-brachial index

Education:

Congestive heart failure is caused by the inability of your heart to pump blood effectively enough to meet the demands of your body. If you think of your body as any other pump, if fluid does not move well through the system, then it will back up into other spaces. When blood backs up it puts a lot of pressure on the blood vessels, which forces fluid to leak out into the nearby tissue. With CHF, this fluid usually moves into your lungs, legs, or abdomen.

The signs of worsening CHF include decreased energy level, shortness of breath during your normal routine, increased swelling to your legs and feet, your clothes feel tight, or a wet sounding cough. Call the office if these symptoms occur.

Weigh yourself every morning at the same time. If you have a 3 pound weight gain in 24 hours, or a 5 pound weight gain over a week, you should call the office.

Exercise and maintaining a normal weight is very important. You should try to exercise at least 20-30 minutes a day, more if possible. Start slow with walking.

Decrease your salt intake. Do not add any extra salt to foods. Salt makes you retain fluid, and it makes you want to drink more fluid. Avoid fast food and prepared food as they are usually very high in sodium.

If you notice your legs swelling, elevate them up and rest. Do not drink alcohol and continue to avoid smoking or second hand smoke.

Take your medications as directed, with water. Do not stop them abruptly or skip doses.

I have started you on a medication for depression. It can take 2 weeks to start to feel it working and up to a month until you can fell the real benefits.

If you start to feel more depressed, like you want to harm yourself or others, please contact me right away or got to the ER.

Referrals: may refer based on lab results

Follow up: return to office in 2 weeks to review lab results and adherence to treatment plan.

Additional lab results:

Echo results: LVEF 39%

BNP – 682 pg/ml

Questions:

According to the ACC/AHA Guidelines, what is BJ’s heart failure stage? Include the pertinent positives (the signs and symptoms AND the objective data) to support this finding. Cite your reference.

According to the ACC/AHA Guidelines, what medications should BJ be prescribed? Include the drug class and rationale statement for each medication listed. Cite your reference for each medication.

Given her history of MI, what additional medications will you prescribe? Include the drug class and rationale statement for each medication listed. Cite your reference for each medication, prescribed or OTC .

Write her complete prescriptions using the prescription writing format. NR601 Week 1 Discussion Part 1 & 2 Latest

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:

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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. NR601 Week 1 Discussion Part 1 & 2 Latest

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? NR601 Week 4 Discussion Case Study Papers

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.

NR601 Week 5 Discussion Case Study – Part 1 and Part 2

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? NR601 Week 1 Discussion Part 1 & 2 Latest

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. NR601 Week 1 Discussion Part 1 & 2 Latest

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.

PART 1

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. NR601 Week 1 Discussion Part 1 & 2 Latest

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 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 Primary Care of the Maturing and Aged Family

Week 2 Discussion – DQ1 Polypharmacy

Polypharmacy is a common concern, especially in the elderly.

List the definitions of polypharmacy you encounter in your assigned reading. Include an additional reference from an evidence based practice journal article or national guideline.

Discuss three risk factors that can lead to polypharmacy. Explain the rationale for why each listed item is a risk factor. Risk factors are different than adverse drug reactions. ADRs can be a result of polypharmacy, and is important, but ADRs are not a risk factor.

Discuss three action steps that a provider can take to prevent polypharmacy.

Provide an example of how your clinical preceptors have addressed polypharmacy.

Discussion Guiding Principles

The ideas and beliefs underpinning the discussions guide students through engaging dialogues as they achieve the desired learning outcomes/competencies associated with their course in a manner that empowers them to organize, integrate, apply and critically appraise their knowledge to their selected field of practice. The use of discussions provides students with opportunities to contribute level-appropriate knowledge and experience to the topic in a safe, caring, and fluid environment that models professional and social interaction. The ebb and flow of a discussion is based upon the composition of student and faculty interaction in the quest for relevant scholarship. Participation in the discussion generates opportunities for students to actively engage in the written ideas of others by carefully reading, researching, reflecting, and responding to the contributions of their peers and course faculty. Discussions foster the development of members into a community of learners as they share ideas and inquiries, consider perspectives that may be different from their own, and integrate knowledge from other disciplines.

DQ2 ACC/AHA Guidelines Discussion

Chief complaint: medication refill “ran out of medicine”

PMH:

Hypertension

Previous history of MI in 2010

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

Social history:

High school graduate, a widow with one son who loves out of state. She drinks one 4-ounce glass of red wine daily. She is a former smoker that stopped 20 years ago.

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.

ROS:

Constitutional: Lightheaded and faint with exertion.

Respiratory: Shortness of breath with exertion (playing with grandchildren and stairs). + Orthopnea

Cardiovascular: + leg and ankle swelling x 1 week

Psychiatric: Not taking medications for 6 months – “ran out”

Physical examination:

Vital Signs

Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8 BP 150/86 T 98.0 oral P 100 R 22, non-labored;

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: inspiratory crackles

HEART: Normal S1 with S2 split during expiration. An S4 is noted at the apex; systolic murmur noted at the right upper sternal border without radiation to the carotids.

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

GENITOURINARY: no CVA tenderness; not examined

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.

Labs:: Hgb 12.2, Hct 37%, K+ 4.2, Na+140, Cholesterol 230, Triglycerides 188, HDL 37, LDL 190, TSH 3.7, glucose 98 BUN 12 Cr 0.8

Primary Diagnosis:

Congestive Heart Failure (CHF) (150.9)

Secondary Diagnoses:

Primary Hypertension (I10)

Depression F32.3:

Obesity (E66):

Osteoarthritis (OA) (715.90)

Differential Diagnosis:

Peripheral Vascular Disease (PVD) (173.9)

Medications:

Sertraline 25 mg. Take 1 tab PO QD disp#30, 1 refill

Tylenol 650 mg PO Q4 hours as needed for arthritis pain

Labs: UA; Brain natriuretic peptide (BNP); LFTs and TSH.

12-lead EKG, Chest X-ray; Initial 2D echo with Doppler; Ankle-brachial index

Education:

Weigh yourself every morning at the same time. If you have a 3 pound weight gain in 24 hours, or a 5 pound weight gain over a week, you should call the office.

Exercise and maintaining a normal weight is very important. You should try to exercise at least 20-30 minutes a day, more if possible. Start slow with walking.

If you notice your legs swelling, elevate them up and rest. Do not drink alcohol and continue to avoid smoking or second hand smoke.

Take your medications as directed, with water. Do not stop them abruptly or skip doses.

I have started you on a medication for depression. It can take 2 weeks to start to feel it working and up to a month until you can fell the real benefits.

If you start to feel more depressed, like you want to harm yourself or others, please contact me right away or got to the ER.

Referrals: may refer based on lab results

Follow up: return to office in 2 weeks to review lab results and adherence to treatment plan.

Additional lab results:

Echo results: LVEF 39%

BNP – 682 pg/ml

Questions:

According to the ACC/AHA Guidelines, what is BJ’s heart failure stage? Include the pertinent positives (the signs and symptoms AND the objective data) to support this finding. Cite your reference.

According to the ACC/AHA Guidelines, what medications should BJ be prescribed? Include the drug class and rationale statement for each medication listed. Cite your reference for each medication.

Write her complete prescriptions using the prescription writing format.

NR 601 Primary Care of the Maturing and Aged Family

Week 3 Discussion

DQ1 Geriatric Assessment Tools

Review the course library page list of available screening tools. Link to Library (Links to an external site.)

Scroll down and look on the left hand side of the screen: Geriatric Assessment tools

Choose two assessment tools that are appropriate for primary care (excluding depression, anxiety and pain screening tools) and discuss the following:

explain the purpose of the tool

scoring guidelines

how you apply the assessment in practice

*If you would like to present a screening tool that is not listed, contact your instructor for approval.

DQ2 Psychiatric Disorders and Screening

Anxiety and depression are the most common psychiatric problems you will encounter in your primary care practice.

Review this case study

HPI: KB, 55 year old Caucasian female who presents to office with complaints of fatigue. The fatigue has been present for 6 months and seems worse in the morning, improving slightly through the day. KB reports a lack of energy and “loss of joy”. States” I really don’t feel like going anywhere or doing anything” Reports she often has difficulty staying on task and completing projects for work. She reports not feeling hungry and does not feel rested when she wakes up in the morning. KB is a widow for 2 years, social events that are couples only can make her symptoms worse. She tries to do at least one social activity a week but it can be really exhausting. Her husband died in their car while she was driving him to the hospital and sometimes driving in that car makes all the memories come back. She recently got a puppy, which she thought would help with the loneliness but the care of the puppy seems overwhelming at times. Rest and exercise, specifically yoga and meditation seem to make her feel better. At this time she does not want to do either. She has not tried any medications, prescribed or otherwise. She reports drinking a lot of coffee, but that does not seem to help.

Current medications: Excedrin PM about once a week when she can’t sleep, seems to help a bit. NKDA.

PMH: no major illnesses. Immunizations up to date.

SH: widowed, employed full time as a manager. Drinks wine, 1 glass every night. No tobacco, no illicit drugs. Previously married while living in France, reports an abusive relationship. The French government gave custody of her son to the ex-husband. She returned to US without her son 10 years ago. She sees her son two times a year, they skype and text “all the time” but she misses him.

FH: Parents are alive and well. Has one son, age 21, he is healthy but lives in France with his father.

ROS

CONSTITUTIONAL: reports weight loss of 2-3 pounds, no fever, chills, or weakness reported

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough or sputum.

GASTROINTESTINAL: Reports decreased appetite for about 3 months. No nausea, vomiting or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

GENITOURINARY: no burning on urination. Last menstrual period 4 years ago.

PSYCHIATRIC: No history of diagnosed depression or anxiety. Reports great anxiety due to verbal and concern for physical abuse, reports feeling very sad and anxious when divorcing and leaving her son in France. Did not seek treatment. She started to feel better after about 4 months.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia

ALLERGIES: No history of asthma, hives, eczema or rhinitis.

Discussion Questions:

undefinedResearch screening tools for depression and anxiety.

Choose one screening tool for depression and one screening tool for anxiety that you feel are appropriate to screen KB.

Explain why you chose that particular tool for KB. Score KB based on the information provided (not all data may be provided). Include what questions could be scored, and your chosen score. Assume that any question topics not mentioned are not a concern at this time.

2. Identify your next step for evaluation and treatment for KB. Include any necessary physical medicine evaluation.

3. What medication, if any, would you recommend for treatment? Provide the rationale. This should include the medication class, mechanism of action of the medication and why this medication is appropriate for KB. Include initial prescribing information and education to include side effects and when KB should notice efficacy. NR601 Week 1 Discussion Part 1 & 2 Latest

4. If the medication works as expected, when should KB expect to start feeling better?

NR 601 Primary Care of the Maturing and Aged Family

Week 6 Discussion

DQ1 Post Menopausal and Sexuality Issues in the Maturing and Older Adult

Students will not receive credit for any discussions posted after Sunday 11:59pm MT.

Ageism and gender bias can affect who and how we ask about sexual health, sexual activity, and concerning symptoms. Depending on your own level of comfort and cultural norms this can be a tough conversation for some providers. But this is an important topic and as our videos discussed, women are wanting us to ask about sexual concerns. This week we also reviewed sexually transmitted diseases and the effects of ageism on time to diagnosis so it is necessary to ask these questions and provide good education for all patients. You will not know any needs unless you ask.

Discussion Questions:

Review the required NAMS videos. What was the most surprising thing you learned about in the videos? Explain why it was surprising.

What is GSM? What body systems are involved? How does this affect a woman’s quality of life?

What treatment does Dr Shapiro recommend?

Review one aspect of treatment that Dr Shapiro recommends and include an EBP journal article or guideline recommendation in addition to referencing the video in your response.

Sexuality and the older adult

What is your level of comfort in taking a complete sexual history? Is this comfort level different for male or female patients? If so, why?

How will this information impact the way you will interact with your mature and elderly clients?

DQ2 Urologic Concerns in the Maturing and Older Adult

Men and women both can experience urologic concerns with aging. This week’s presentations and readings covered urologic concerns and common problems. Utilize the national guidelines and scholarly references to develop your responses.

Urinary Tract Infections

What risk factors contribute to the development of a UTI in men versus women?

In which sex is a UTI more concerning and why?

It is important to know when to treat a UTI and when not to treat. Is there a particular situation where you would not treat a UTI?

BPH

As a provider it is essential for you to know to interpret DRE findings and what your next step should be. The American Urology Association has specific recommendations based on age. Be sure you know these because the guidelines will guide your patient counseling and treatment plan.

What does the AUA state about drawing PSA levels?

If you do decide to draw a level what specific counseling should you include in your education today? NR601 Week 2 Discussion Case Study Assignment

NR 601 Primary Care of the Maturing and Aged Family

Week 7 Discussion

Reflection

Reflect back over the past seven weeks and describe how the achievement of the course outcomes in this course have prepared you to meet the MSN program outcome #5, the MSN Essential VIII, and the Nurse Practitioner Core Competency # 8 Ethics Competencies.

Chamberlain College of Nursing Program Outcome #5

Advocates for positive health outcomes through compassionate, evidence-based, collaborative advanced nursing practice. (Extraordinary nursing)

Masters Essential VIII: Clinical Prevention and Population Health for Improving Health

Design patient-centered and culturally responsive strategies in the delivery of clinical prevention and health promote on interventions and/or services to individuals, families, communities, and aggregates/clinical populations.

Integrate clinical prevention and population health concepts in the development of culturally relevant and linguistically appropriate health education, communication strategies, and interventions.

NONPF: #8 Ethics Competencies

Integrates ethical principles in decision making.

Evaluates the ethical consequences of decisions.

Applies ethically sound solutions to complex issues related to individuals, populations and systems of care. NR601 Week 1 Discussion Part 1 & 2 Latest