M10 Case Study

• Points 76

CHIEF COMPLAINT: Fatigue

HISTORY OF PRESENT ILLNESS

M.W., a 78-year-old female widow, presents to urgent care with the chief complaint of feeling very tired lately. She also complains of some nasal congestion. She arrives with her daughter, who provides some gaps in the medical history. The daughter notes that M.Ws fatigue has been a complaint for about 16 months.

Further review of systems provided by the daughter reveals a concern that her mother seems to have slight confusion, increased fatigue, poor appetite, and a bitter taste sensation when eating. M.W. eats 3 small meals daily, and shes had some unintentional weight loss over the past few months. She reports a marked decrease in energy level. She denies nausea, vomiting, or emotional lability. She does not eat red meat.

PAST MEDICAL HISTORY: Significant for hypertension for many years; type 2 diabetes mellitus that is not well controlled on oral meds; high cholesterol for many years; lymphedema in lower extremities bilaterally since adolescence; benign lung densities per chest x-ray; and a report of Mediterranean anemia. She sees a podiatrist every 3 months and sees a retinopathist periodically.

PAST SURGICAL HISTORY: She had cataract removal surgery in 2009. Her last visit was today, and her exam was negative.

CURRENT OUTPATIENT MEDICATIONS

• Glucophage, 1000 milligrams BID
• Avandia, 4 mg daily
• Protonix, 40 mg daily
• Glucotrol, 10 mg daily
• Aricept, 10 mg daily at night
• Cardia, 240 mg daily in AM
• Lisinopril, 10 mg daily
• Diovan, 160/12.5 BID
• Aspirin, 81 mg daily
• Crestor, 5 mg daily
• Zetia, 10 mg daily
• Coreg, 12.5 mg BID
• Lasix, 20 mg daily
• Potassium, 10 mEq daily
• Actonel, 35 mg weekly.
• Multivitamin, over the counter
• B12
• Tylenol, as needed for pain

ALLERGIES: No known drug allergies and is up to date on her immunizations.

Family History: Her mother died at age 81 with DM and hypertension. Her father died of lung cancer. She has two brothers ages 81 and 83, both with hypertension and one with prostate cancer.

Social history: Born in California and has four children. She does not drink coffee and does not exercise. Her typical day includes watching television and doing housework. She lives independently in an adult community in Alabama and has a homemaker 3 times weekly. She is a retired cook. She has one daughter who lives nearby.

BEHAVIORAL: Does not use tobacco currently; quit smoking over 20 years ago. She denies ETOH use or history of substance abuse

REVIEW OF SYSTEMS:

HEENT: Denies any dizziness or blurry vision. No headaches except for + right ear pain. Sometimes difficulty swallowing.

Respiratory: Occasional cough and has noticed more shortness of breath recently. Sleeps on 2 pillows.

CV: Denies chest pain or palpitations. Denies numbness to upper and lower extremities.

GI: Denies abdominal pain or bloating. She does not have any regurgitation. No nausea or vomiting. She has a bowel movement daily which is normal, brown in color, and normal consistency. She does not report any blood in her stool.

Neurological: Reports fatigue. Denies weakness, numbness, slurred speech.

General/Constitutional: Generally happy, social, but most recently not engaged due to fatigue and weakness.

Musculoskeletal: Reports joint pain in her knee, especially her left knee.

Dermatological: Complains of dry skin.

PHYSICAL EXAMINATION

General: She is a 78-year-old female who is pleasant, slightly confused, and moderately anxious. Her daughter is present during the visit. The patient defers to her daughter for clarification of events and details. Daughter and mother have a positive working relationship with evidence of support and caring.

Vital signs: T: 98.2; P: 86; RR: 28; SaO2: 93; B/P: 140/70. Her weight is 191 pounds, and her height is 64 inches. General: Overweight and in no mild distress.

Skin: Clear, slightly grayish color.

HEENT: Hair thinning, gray at roots, silky texture. Sclera nonicteric, pupils dilated since she just came from the retinopathist (examination of her eyes deferred). Oral mucosa, pink moist intact. Supple, no JVD, no bruits. Thyroid nonpalpable. No lymphadenopathy.

Resp: Lungs clear to auscultation. Transverse/AP diameter 2/1.

Heart: Heart regular rate and rhythm. PMI is at 5th intercostal space left sternal border; + systolic murmur II/VI. Pulses positive all extremities.

Abdomen: BS+, obese, soft, nontender. No hepatomegaly; no splenomegaly; no hernia.

Extremities: There is bilateral lower leg edema; chronic lymphedema; no ulcerations; skin intact; no hair growth; no pitting.

Musculoskeletal strength: Walks with a cane; s/p right knee replacement 2007. Full ROM; no deformities; muscle strength appropriate for age.

Neurological: Alert, oriented 3, follows command to bilaterally, visual fields intact, extraocular movements intact. Slightly confused, and moderately anxious. CN IXII grossly intact. Mental status 30/30 (Folstein Mini Mental Status Exam). Geriatric depression screen: No evidence of depression.

DIAGNOSTICS

Laboratory Findings:

CBC: WBC 8K, Hemoglobin and hematocrit were 10.1/29.5, PLT 160

FBS: 149

BMP: Sodium 135, potassium 4.8; BUN: 42; creatinine 1.44 (estimated glomerular filtration rate [GFR] was 35)

A1C of 5.3, and negative troponins.

Chest X-ray: mild pulmonary congestion

ECG: showed sinus rhythm with a heart rate of 72bpm.

Based on the main diagnosis of this patient you, the nurse practitioner identify, you will submit your case study completed in the sections identified below:

1. Definition of diagnosis you suspect in this patient
2. Epidemiology
3. Etiology/Classification
4. Risk Factors of the diagnosis – emphasize with an asterisk (*) the risk factors this patient exhibits
5. Pathophysiology
6. Clinical Presentation (including History and Physical Exam pertinentfindings of the typical presentation of this diagnosis)
7. Diagnosis (including criteria, laboratory findings, imaging)
8. Management of the disease
9. Prevention of recurrence
10. Complications and Prognosis

Bonus- Differential Diagnoses. If you accurately list the pertinent differential diagnoses for this patient, you will be awarded bonus points per the rubric.

Note: Use 3 or more references. List your content in sections denoting the headings 1-10 and in the order listed above. Bonus differential diagnoses can be included at the end of your submitted case study.

Rubric

Case Study Rubric Week 10

Case Study Rubric Week 10

Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeEpidemiology, Etiology/Classification & Risk Factors	16 ptsExcellentComplete inclusion of epidemiology, etiology/classification data, and pertient risk factors12.44 ptsGoodIncomplete inclusion of epidemiology, etiology/classification data, and pertient risk factors. Missing 1-4 data points. 8.89 ptsFairIncomplete inclusion of epidemiology, etiology/classification data, and pertient risk factors. Missing 5 or more data points.0 ptsNo MarksNo inclusion of content for this topic	16 pts
This criterion is linked to a Learning OutcomePathophysiolgy	21 ptsExcellentComplete inclusion of pathophysiology content16.5 ptsVery GoodIncomplete inclusion of pathophysiology content. Missing 1-2 data points. 10.5 ptsGoodIncomplete inclusion of pathophysiology content. Missing 3-4 data points.6 ptsFairIncomplete inclusion of pathophysiology content. Missing 5 or more data points.0 ptsNo MarksNo inclusion of content for this topic	21 pts
This criterion is linked to a Learning OutcomeClinical Presentation & DiagnosisClinical Presentation (including History and Physical Exam pertinent findings), Diagnosis (including criteria, laboratory findings, imaging)	19 ptsExcellentComplete inclusion of clinical presentation & diagnosis criteria. Missing no more than 1 data points.15.83 ptsGoodIncomplete inclusion of clinical presentation & diagnosis criteria. Missing 2-4 data points. 11.08 ptsFairIncomplete inclusion of clinical presentation & diagnosis criteria. Missing 5 or more data points.0 ptsNo MarksNo inclusion of content for this topic.	19 pts
This criterion is linked to a Learning OutcomeManagement of the Disease, Prevention of Recurrence & Complications and Prognosis	16 ptsExcellentComplete inclusion of management of the disease, prevention of recurrence & complications and prognosis data points. Missing no more than 1 data points.12.44 ptsGoodIncomplete inclusion of management of the disease, prevention of recurrence & complications and prognosis data points. Missing 2-4 data points. 8.89 ptsFairIncomplete inclusion of management of the disease, prevention of recurrence & complications and prognosis data points. Missing 5 or more data points.0 ptsNo MarksNo inclusion of content for this topic.	16 pts
This criterion is linked to a Learning OutcomeBonus: Differential Diagnosis	0 ptsFull MarksAccurately list the 3-4 most pertinent differential diagnoses for this patient in order to receive points.0 ptsNo MarksNo partial points will be awarded.	0 pts
This criterion is linked to a Learning OutcomeReferences3 or more references listed in APA format.	4 to >0.8 ptsExcellent3 references. Correctly cited. Appropriate quality resources.0.8 to >0 ptsNo Marks	4 pts

Total Points: 76

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