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Case Study #2GERO CASE STUDY - Fall 2011Use the following template to complete your answers to this case study and resubmit via tigermail on or before the due date.SCENARIOAmy Michaels is a 65-year old widowed Asian female, first visit, requesting a physical exam for the Foster Grandparents Program. Ann has not seen a family physician since she went through natural menopause 17 years ago. She requested an appointment during the day because of difficulty driving at night, but is otherwise enjoying "good health."TENTATIVE DIAGNOSESBased on the information provided so far, what are the potential diagnoses?Diagnosis not applicable at this time - well visit.HISTORYBelow is the history obtained from Ann. What are the significant findings that will help you narrow down to a specific diagnosis for Ann? Significant findings highlightedRequested DataData AnswerAllergiesNoneMedicationsTylenol/Advil prn headache and arthritic pain; multivitamin with iron; infrequent MaaloxChildhood diseases Chicken pox, measles, mumpsImmunizationsUnknown for childhood illness and tetanus. Has not received influenza, pneumococcal, or hepatitis B vaccines.Surgery/transfusionsAppendectomy 25 years ago. NoneHospitalizationsVaginal delivery w/o complications x 2 - 1955, 1959.Fractures, accidences, injuriesMild cervical neck strain from MVA 1987 (seen at Urgent Care, no further problemsAdult illnessPneumonia, 1977; infrequent coldsOB/GYN history LMP Las pelvic/PAP Mammogram/SBE Gravida/para19801979 or 1980Never/neverG2 P 2 A oLast complete PEProbably last pregnancyLast eye exam4 years ago; began wearing bifocals at age 47; sees halos around lights at nightLast dental exam3 years ago; has all natural teethFamily historyParents died 30 years ago in MVA; not aware of prior illnessMaternal grandmother; 98 y/o; "healthy" but has cataracts & arthritis1 living brother; 56 y/o; hypertension3 living sisters; 59 y/o, 61 y/o, 63 y/o; 1 w/ CAD & 1 w/ hypertension2 healthy children; 42 & 38 y/o men, good healthSocial HabitsNonsmoker, occasional social drink, drinks 1 cup of coffee & 1 cup of tea per day, no recreational drugs, walks several miles a day during nice weather and maintains her flower & vegetable gardensSocial groupsChurch choir; anticipating Foster Grandparents ProgramRelationship with familyAssists maternal grandmother w/ shopping, lunch together weekly, siblings are supportive and interactive when possible, but "very busy" with own families; sons very protective since death of their father, assist mother with house-hold chores, grandchildren visit at least weekly with sonsPhysical activity and functional status at homeAble to care for self; shops, cleans, performs all ADLs. Sons help with home repair and maintenance. Still able to drive own car, although does not like to drive at night anymore.Insurance/incomeMedical and dental insurance through AARP and Medicare; income through husband's pension and Social Security benefits.HomeOwns her own home, ranch style w/ basement, lives within five miles of both sons.Appetite, 24-hour diet recallB: Juice, toast, grapefruit or cereal with 2% mild, coffeeL: Soup and crackers or grilled cheese sandwich, fresh or canned fruit, 2% milkD: Tea, baked potato with cheese, peas, cakeS: YogurtSleeping patternSleeps 11/11:30 to 7/7:30. Usually up x 1 to void.How do you handle stress? How would you rate your life on scale from 1 to 10 (10 best)?Rating 3. Handles stress by increasing activities and talking with friends and family. REVIEW OF SYMPTOMSBelow are key points of ROSSYSTEM REVIEWEDDATA ANSWERGeneralNo acute distressGIDenies black, tarry, or bloody stools or emesis. No constipation.GUDenies problems with urinating, burning, frequency, or emptying her bladder.LungsDenies SOB, cough.CardiacDenies sweating radiation of pain to arm or neck. No SOB or palpitationsPHYSICAL EXAMSignificant portions of PE based on Ann's complaintsSYSTEMFINDINGSVital signsT = 97.6 (o), P = 80 and reg, R = 12 easy, B/P 160/92, RA sitting and standing, 158/90 LA sitting, Height 64 1/2", Weight 125 lbs.General appearanceWell-nourished white female. Appears her stated age. Alert, oriented, affect appropriate.SkinWarm and dry; no jaundice, bruises, ulcerations, rash. Negative for clubbing or cyanosisHEENTNormocephalic; normal hair distribution, PERRLA, sclera clear, conjunctiva pale, fundoscopic-bilateral lens opacification, red reflex present, unable to visualize retinal details, EOMS intact; Visual acuity 20/40 OS 20/60 OD with corrective lenses, TMs and canals clear, Weber lateralizes appropriately, Rinne AC > BC; nares patent, turbinates sl. pale and edematous; oropharynx clear, mucous membranes pink and moist, no ulcerations noted, tongue symmetrical, uvula midline; negative sinus tenderness; neck supple, neg. adenopathy, tenderness, thyromegaly, bruits, JVD.CardiopulmonaryCardiac: No chest wall abnormalities; neg. thrills, PMI at 6th intercostal space 1 cm to left of MCL; reg. rhythm w/ occas. extra systoles, S1, S2 (accentuated) w/ soft S4. Grade II/VI systolic ejection murmur at left sternal border. Lungs: Diaphragmatic excursion WNL, CTA, and percussionAbdomenSI. rounded, striae present, BS x 4 quads, tympany throughout, soft, nontender, neg. mass or organomegaly, CVA tendernessBreastsSymmetrical, neg. dimpling, nontender, 1 cm mobile, firm nodule left breast in 6 o'clock position inferior to areola, neg. axillary or supraclavicular adenopathy or nipple dischargeGenitourinaryExternal genitalia w/o lesions, ulceration, or discharge. Vaginal vault neg. discharge, ulceration, min. erythema w/ sl. dry mucosa, cervix mild inflammation, PAP smear obtained with brush and spatula; neg. pain w/ cervical motion, adnexal mass or tenderness; uterus retroflexed approx. 8 weeks in size. Rectal: Good sphincter toneOrthopedicROM w/o pain or limitation of movement; neg. erythema, edema, pain w/ palpation; click present right knee; peripheral pulses 2+ bilateral; cap. refill briskNeurologicalCN II-XII intact, DTRs 2+ bilateral upper & lower extremities; no tremors noted; gait normal; Romberg neg; flexion & extension strength equal bilateral; discrimination of pain intactDIFFERENTIAL DIAGNOSESProvide the significant positive and negative data that support or refute your diagnoses for Ann.DIAGNOSISPOSITIVE DATANEGATIVE DATAHTNBP 160/92, age, family history, vision changes normal BMI (21.5), nonsmokerDecreased visual acuity - possible glaucomaDifficulty driving at nightSees halos, wears bifocals, bilateral lens opacification, 20/40 OS, 20/60 OD with corrective lenses, agePERRLA, Sclera clear, no eye pain. No history of prolonged corticosteroid use, no family historyBreast nodule1 cm mobile, firm nodule left breast, female, age,Normal BMI, no family history, no HRT, no excessive alcohol intakeOsteoporosisAsian female, age, small body frame, arthritic pain, menopause, no prior hormone replacements, no calcium supplementsNonsmoker, not excessive alcohol intake, not on thyroid replacement therapy, no corticosteroid therapy, no renal diseaseDeficient GYN maintenanceLast pelvic/PAP 1980, SBE/mammogram neverDeficient immunizationUnknown tetanus, has not received influenza, pneumococcal or hepatitis B vaccinesDIAGNOSTIC TESTSBased on the history and PE the following diagnostic tests were ordered. The test and results are provided. You will need to provide a rationale to support the use of the test for Ann or provide documentation why you would not order this diagnostic test in this case.DIAGNOSTIC TESTRESULTSRATIONALEPPD skin test+ skin test, 10 cm indurationPPD to test for tuberculosis, has no S/S but may be a requirement for the Foster Grandparent programU/A; CBC, electrolytes, renal panel, liver panel, uric acid, T4, TSH, nonfast, cholesterol & HDLCholesterol 247, HDL 32, otherwise WNLPt has HTN, need baseline labs to monitor for organ damage. UA to check for infections, proteinuria, glucose, ketonesCBC to screen for anemias, infectionsElectrolytes to screen for diabetes.Renal panel for kidney disease screeningLiver panel to screen for liver diseaseUric acid for gout ( would not order this test, has no S/S of gout)T4/TSH screening for thyroid disordersCholesterol and HDL to screen for lipid disordersMammogramBenign calcification lt. breast, Recommend annual mammogramScreening for breast cancer, she has never had screening mammogram and needs one annually. She had a nodule on PE.Fecal occult blood testingNegative hemoccultScreening for colon cancer, needs annually for her ageEKGEKG WNLEKG to r/o arrhythmias, she has HTN and a murmur. Need baseline.Chest radiographCXR essentially normal with few scattered fibrotic changesHad a positive PPD , needs CXR to r/o active infection. Has HTN, check size of heart.Bone densitometryBone densitometry shows risk of fracture for age and osteopeniaBone density for osteoporosis screening, needs every 2 years at her ageDIAGNOSESBased on the data provided, what are the appropriate diagnoses for Ann?List all appropriate diagnoses in priority order. Provide rationale for concluding these diagnoses are correct? HTN: elevated BP on PEOsteoporosis: bone density shows risk of fracture for age and osteopeniaDyslipidemia: Cholesterol 247, HDL 32 on non-fasting labs- would repeat with a fasting lipid profileDecreased visual acuity; possible glaucoma: vision changes , halos, lens opacificationDeficient GYN maintenance: no prior SBE/mammogram, no pelvis/PAP since 1980Underimmunization: no influenza, pneumococcal, tetanus, or hepatitis immunizationsBenign breast nodule: benign calcification on mammogramTHERAPEUTIC PLANProvide answers with scientific basis for the following questions about Ann's treatment plan. Provide APA references when indicated.(1) What influence does Ann's + PPD have on her participation in the Foster Grandparents program? The CXR was negative so there should be no issues. She needs to be told to never have another PPD, she will need a CXR in the future. She is at low risk for TB.(2) What recommendations can you take for Ann in terms of immunizations?She needs the flu yearly, the pneumoccal once, zostavax (history of chickenpox), Tdap(3) What counseling would you do for Ann relative to her health promotion and prevention needs? Address the areas of:Diet: due to osteoporosis she needs to eat a regular well-balanced diet. Increase food sources rich in calcium (dairy products, green leafy vegetables, almonds, tofu and OJ fortified with calcium), protein ( chicken, lean cuts of beef and pork, fish, legumes), and vitamin D ( milk, salmon, cereals with added vit D). Limit caffeine intake.Due to high cholesterol she needs to limit high fat, saturated fat, fried food and fast food. Eat foods that are baked, broiled, grilled or stir-fried. Eat more fruits and vegetables. Avoid whole or 2% milk or dairy products. Limit eggs to 2 yolks week. Use olive,canola or peanut oils.Due to hypertension limit the sodium intake to 1,100-3000 mg daily.Injury prevention: at risk for injuries due to falls. Survey home to look for fall hazards such as rugs, cords and clutter that she might trip over. Have good lighting (night lights) at night when she gets up to use the bathroom with a clear path to the bathroom. Install rails in the bathroom for safety and nonskid pads in the bathtub. Pt has a basement, make sure there is a railing on the stairs and good lighting.Dental health: Make her an appointment with her dentist, recommend dental visits every 6 monthsHormone replacement therapy: Premarin 0.625 mg PO dailyASA therapy: Risk factors are HTN and dyslipidemia. ASA 81 mg PO QDRegular health maintenance: Needs PE yearly. Mammogram every year, if PAP is negative then she will not need to have PAP again due to her age. Bone density every 2 years. Needs referral for colonoscopy since she has never had one, if normal then every 10 years, if polyps then every 5 years. Flu shot yearly.(4) What therapy would you order for Ann for her osteoporosis?Calcium supplement: Os-Cal 500 mg PO 1-3 times dailyVitamin D: 800 mg PO daily with the calcium Biphosphate: Fosamax 70 mg PO weekly or Boniva 150 mg PO monthly depending on pt preferenceHRT: Premarin 0.625 mg PO daily30 minutes of walking at least 3 times a week.(5) What patient education is appropriate relative to the osteoporosis?You have osteoporosis and you need to prevent the disease from progressing and take measures to prevent bone fractures. Use caution when walking on wet, slippery surfaces. Physical activity is vital to maintain and prevent further bone loss. Weight bearing activity is the best activity, such as walking. Avoid high impact sports and activity such as jumping and high impact aerobics to prevent fracturing the bones.Avoid risk of falls. Do not use throw rugs. Bathtubs should have nonskid protection.Get vitamin D from 30 minutes of sun exposure daily.(6) When would you have Ann return for follow up?I would have her come in to repeat the lipid profile fasting, if cholesterol still elevated and HDL still low, then suggest TLC (diet and exercise) for 3 months, and then repeat labs.(7) What referrals should be made for Ann? Gastroenterology for colonoscopyOphthalmologist for vision changes, halos around lights, bilateral lens opacificationGynecologist for uterine enlargementSchedule appointment with her dentist for exam and cleaningReferencesCash J C Glass C A 2011 Family practice guidelinesCash, J. C., & Glass, C. A. (2011). Family practice guidelines (2nd ed.). New York, NY: Springer Publishing Company. 2012082821060193485474Dunphy L M Winland-Brown J E Porter B O Thomas D J 2011 Primary care: the art and science of advanced practice nursingDunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary care: the art and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F.A. Davis Company. 20120828210408683394670Goolsby M J Grubbs L 2006 Advanced assessment: Interpreting findings and formulating differential diagnosisGoolsby, M. J., & Grubbs, L. (2006). Advanced assessment: Interpreting findings and formulating differential diagnosis. Philadelphia, PA: F.A. Davis Company. 201208282108251757256031Seller R H Symons A B 2012 Differential diagnosis of common complaintsSeller, R. H., & Symons, A. B. (2012). Differential diagnosis of common complaints (6th ed.). Philadelphia, PA: Elsevier Saunders. 20120828211010742201686 ................
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