NR 601 Week 7 Health Promotion, Health Protection, Disease Prevention, and Treatment Considerations in End-Of-Life Care:

Differential Diagnosis from Physical Examination Discussion Part One (graded)

A 69-yearl-old male patient known as C.G has a history of neck and right head cancer that you have been interested in for a year. Initially, the carcinoma was localized to the neck and the head- particularly at the left lingual tonsil area and proceeded to finish a radiation and chemotherapy session that lasted a total of six weeks. Lately, the latest PET scan demonstrated certain metabolic activity within the lest lymph node location alongside other regions that had abnormal metabolic activity within the body. These regions specifically entailed the lungs and the liver demonstrating metastasis. Further, C.G. complains that he has gotten fatigued of the impacts of radiation and chemotherapy and consequently is not interested in pursuing further treatment for the cancer.

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Differential Diagnosis from Physical Examination

• 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.

Differential Diagnosis from Physical Examination: Discussion Part Two (graded)

• 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

Differential Diagnosis from Physical Examination 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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