NR 601 Week 2 Case Study: Complete Health History

B.J., a 70-year-old Caucasian female has been seen in the clinic several times over the last 3 years. However, she missed her last annual appointment-last appointment was 18 months ago and today you are the nurse practitioner seeing her. She arrived to the clinic alone and states she is “here for my check-up”.

Background

• The patient reports that “my feet just burn and tingle all the time and it is so much worse at night that I can hardly sleep at all”. She also indicates that “I need some new pillows; I use 3 of them now to just get comfortable at night to sleep. Those pillows help me catch my breath so I can sleep better”.  She also reports dyspnea just walking to the bathroom, but it only happens when her legs are “swole up” and also states, “the coughing also keeps me up at night”.  To be honest, “I’m just tired in general whether my feet are “swole” or not”. She also indicates that she cannot see well, especially at night. She also reported that at her last visit to the clinic, she was told that she had a “heart beat problem” and that she is supposed to be taking aspirin every day. She said she thinks all of her “heart pains” went away after she started taking the aspirin and “putting that pill under the tongue”.  One of her concerns she has today is that since her husband died last year, she tells you, “I just don’t like doing things that I liked to do before my husband died. We used to like to do all sorts of stuff, but anymore….I just feel blue all the time”.
• PMH:
  • Chronic back pain
  • Hypertension
  • Previous history of MI in 2010
• Diabetes?
• Hypothyroidism?
• Constipation?
• Congestive Heart Failure?
• Current medications:
  •             Coreg 6.25 mg PO BID
  •             Colace 100 mg PO BID
  •             Glucotrol XL 10 mg PO daily
  •             Lantus insulin 20 units at HS
  •             K-dur 20 mEq PO QD
  •             Furosemide 40 mg PO QD
  •             L-Thyroxine 112 mcg PO QD
• Aspirin?
• Nitroglycerine?
• 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

NR 601 Week 2 Case Study: Complete Health History Other:

• Has not seen a dentist in over 15 years, the time she got her dentures
• 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%, Hgb A1C 8.2%, K+ 4.2,
• Na+140,Cholesterol 186, Triglycerides 188, HDL 37, LDL 98, TSH 3.7,
• ALT/AST WNL.

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• 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 two sons and their wives live with her, take her to church and to the local senior center; they do all the cleaning, run errands, and do grocery shopping.
• 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:
  • Patient is a current tobacco user and has smoked 1 pack of cigarettes daily for the last 50 years and reports having no desire to quit. She uses occasional chew.  She drinks one 4 ounce glass of red wine daily.

NR 601 Week 2 Case Study: Complete Health History Discussion Part One:

• Provide 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.

NR 601 Week 2 Case Study: Complete Health History Discussion Part Two

• Physical examination:
• Vital Signs
  • Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8   BP 110/70 T 98.0 po P 100 R 22, non-labored; Urinalysis: Protein 2+, Glucose: 4+
• 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: Decreased breath sounds in bases bilaterally with rales, expiratory wheezing with prolonged expiratory phase noted throughout all lung fields. No costovertebral angle tenderness (CVAT) noted. Increase in AP diameter noted.
• HEART: Irregularly irregular rhythm; Unable to detect S3 or murmur
• 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;
• NEUROLOGIC: Achilles reflexes are hypoactive bilaterally. Vibratory perception to the 128 Hz tuning fork placed at the MTP of her great toe is absent bilaterally; She is unable to discern monofilament placement in 3 locations on her left foot and 2 places on her right foot.
• 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.

NR 601 Week 2 Case Study: Complete Health History 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.