Comprehensive Case Study- Expert Evaluation of a 69-Year-Old Male Presenting with Chest, Exams of Nursing

Download Comprehensive Case Study- Expert Evaluation of a 69-Year-Old Male Presenting with Chest and more Exams Nursing in PDF only on Docsity! Comprehensive Case Study- Expert Evaluation of a 69-Year- Old Male Presenting with Chest Pain in an Outpatient Clinic Setting iHuman Case Analysis Week #4 (CLASS 6531) LATEST 2024 HX Performance Hx Performance You asked 60 unique questions 26 were key questionsistatements suggested by the expert case author, You also asked an additional 34 unique questions X Missed Questions You didn't ask all important questions suggested by the expert author for this case You missed asking 16 of the 42 key questions (Nofe: Sometimes there is more than one way to get similar information from your patient. Eliciting information in more than one way when intetviewing 2 patient can be useful ) Reason for Encounter Sx/Sx Characteristics: How can | help you today? Was there 4 popping sensation? How long does your back pain last? Have you had the pain in your back before? Any change in your back pain since # began? ‘Does anything make the pain in your back better or worse? Associated Sx/Sx Characteristics: * Do you feel a lack of coordination? * Do you have muscle pain or cramping? + Do you have joint or bone pain? * Does the pain get worse with breathing? * When you urinate do you feel that you cannot completely empty your bladder? + When did your problem with weakness start? Risk Factors: PMH: * Have you ever been hospitalized? Etiology: * Have you recently lifted something heavy or used your back in unusual ways or postures? * Have you had any trauma to your back? HPI/ROS: * When did you last take your medications? © All Questions Asked You asked 60 questions Reminder: Be sure to fill out appropriate portions of the EHR before proceeding. Comprehensive Case Study- Expert Evaluation of a 69-Year- Old Male Presenting with Chest Pain in an Outpatient Clinic Setting iHuman Case Analysis Week #4 (CLASS 6531) LATEST 2024 Exams Feedback X Missed administer gross pain stimulus e You administered a pain stimulus to a conscious patient. auscultate abdomen © You didn't listen for at least 5 seconds at RLQ. auscultate lungs You did not auscultate in the correct order. e You documented left lung and right lung correctly. examine pupils © You need to examine each pupil at least twice. © You documented left pupil and right pupil correctly. palpate abdomen In a patient presenting with back pain, a full abdominal exam is critical to look for etiologies that might include referre] pain from internal organs, masses or vascular issues (€.g., AAA). percuss back and spine Back percussion is an important exam in individuals with back pain as a way to more precisely localize the discomfort. Significant pain with light percussion of the spine is a feature of infections, fractures and neoplasms. pulse You did not check radial pulse first on conscious adult patient, e You documented rate, rhythm, and strength correctly. reflexes - deep tendon The neurologic examination in this patient is a crucial component as abnormalities cannot only determine if there is neurologic impairment, but can also localize the pathologic process. © You did not check all the locations. Teflexes - plantar/Babinski (L5/S1) © You did not finish performing your exam for both feet. sensory tests (light touch, pain, position, temperature, vibration) The neurologic examination in this patient is a crucial component as abnormalities cannot only determine if there is neurologic impairment, but can also localize the pathologic process. Straight leg raise Straight leg raise is used as an evaluation for herniated disc disease and/or muscle contraction. Exercise #1 Comprehensive Case Study- Expert Evaluation of a 69-Year- Old Male Presenting with Chest Pain in an Outpatient Clinic Setting iHuman Case Analysis Week #4 (CLASS 6531) LATEST 2024 Your Findings Case Findings Key Finding MSAP Key Finding MSAP Relation Relation Sudden sharp stabbing middle to lower MSAP Severe lower back pain since this MSAP back pain 11/40 morning (11-3); Pain radiation into R>L Gait ataxia RELATED ue: ; Saddle parestesia RELATED Fontaine te pee een || Be Lumbar tenderness/spasm RELATED Saddle paresthesia RELATED Back Pain radiates to right leg RELATED ‘Gaitataxia RELATED enlarged prostate RELATED Leg weakness bilaterally RELATED Enlarged R femoral lymph node RELATED Tachycardia RELATED Noncompliance HTN & BP meds RELATED Diminished reflexes on R patelia RELATED tachycardia/Hypertension RELATED Enlarged femoral lymph nodes RELATED 78-9 tenderness RESOLVED PMH Hep C UNRELATED Painful Grimace/reluctance to move RELATED Elevated blood pressure (154/96) UNRELATED HTN; was treated in past UNRELATED Moderate mid-back pain x months (T8) UNKNOWN | Lack of medical care x 6 years UNKNOWN Hx smoking UNKNOWN Hx IVDA UNKNOWN Feedback The medical key findings list you have compiled should be a list that includes everything that is out of the ordinary about this patient, even when it is not a "problem" in the true sense of the word In this case, the most significant active problem (MSAP) Is the acute onset of severe, lower back pain. It is important to mentally review the various processes that could be the cause of the pain. in addition, it is important to look at the list of complaints and determine whether they can be grouped into: 1) related findings suggesting a common cause. 2) unrelated findings. 3) resolved oF non-related findings or PMH. and 4) unknown findings. Mentally review some basic causes of back pain: 1) infection. 2) malignancy, 3) nerve root compression (mass effect ie. bleed, disk hemiation), 4) fracture (compression fracture due to loss of calcium structure or trauma), or 5) muscle sprain/strain. Next, attempt to group the list of pertinent findings into those that are related. Does this list provide any clues into which of the 5 options listed above are most likely? Which are least likely? Look at the patient's medical history of HTN (currently untreated), smoking, intravenous drug use. prostate enlargement and Hep C. Which of these previous conditions might be involved in his current condition? Which ones are not relevant? Finally, the patient presents with tachycardia. What is the cause? Does this reflect volume loss, response to pain, deconditioning and obesity, cardiac conduction problem or something else? Problem Statement Feedback Your Problem Statement Mr Newton is a 62-year-old male caucasian patient presenting to the clinic with a complaint of acute onset lower back pain of 11/10 intensity The pain is sharp, stabbing, and radiates to the RLE with a "pins and needies” sensation. It has not improved with OTC meds or rest. While he has been unable to participate in all physical exams related to pain, he also presents with saddle and leg weakness, gait ataxia, and lumbar spine tendemess/spasms. Additionally, Mr Newton has enlarged femoral lymph nodes and an enlarged/nontender prostate with right-sided nodules. He has been noncompliant with his BPH medication for several years. He is also hypertensive and tachycardic. Case Problem Statement S_ N. is a 62 y/o male who presents with acute onset of severe (11/10) lower back pain that started this moming after getting out of bed. Hx is also significant for moderate/chronic mid-thoracic back pain for 2-3 months. Physical exam reveals tachycardia, elevated blood pressure (154/96), femoral adenopathy, enlarged nodular prostate. diminished R patella reflex, bilateral leg weakness, ataxic gait, saddle paresthesias and bilateral sciatica with standing. Past medical history and risk factors are significant for smoking and IV drug use. Comprehensive Case Study- Expert Evaluation of a 69-Year- Old Male Presenting with Chest Pain in an Outpatient Clinic Setting iHuman Case Analysis Week #4 (CLASS 6531) LATEST 2024 Differential Feedback Differential Ranking Feedback Diagnosis Metastatic cancer causing cauda equina syndrome are the final diagnoses. Because we cannot be certain of the prostate as the malignant cause without tissue confirmation, i.e. biopsy, metastatic cancer is accepted as a correct diagnosis. My Plan: Your Plan Primary Diagnosis: Cauda equina syndrome (CES) 2nd to Metastatic Cancer Status/Condition: Guarded Code Status: FULL Allergies: NDKA Admit to Unit: Nuero ICU Activity Level: Bedrest Diet: NPO, Meds with Sips IVF: NS@100ce/hr Critical Drips: N/A Respiratory: -RT Titrate to 02 Sat 92% and above PRN Medications: -Lotensin HCT 10mg Q day -Dexamethasone 10mg IV once NOW -Dexamethaosne 4 mg IV q 6 hours -Ketorolac 30mg IV Q 6 hours PRN Tramadol 100 mg Q 4 hours PRN Nursing Orders: -Insert PIV -Insert Foley Cath Strict 1&0 -Spinal Precautions -SCD for VTE, Keep on at all times -Obtain consent for old records from the patient's PCP -Ice to Lumbar spine Follow Up Lab tests: CBC inAM CMP in AM PT/INR in AM PTT inAM Diagnostic testing: -CT Myelogram for Surgical Planning -Image Guided Prostate Biopsy Consults: -Emergency neurosurgery Consult: Assess the need for surgical decompression -Oncology for Malignant Compression/Plan of Care -Rehabilitation Services: Mobility Plan of Care Comprehensive Case Study- Expert Evaluation of a 69-Year- Old Male Presenting with Chest Pain in an Outpatient Clinic Setting iHuman Case Analysis Week #4 (CLASS 6531) LATEST 2024 Plan Feedback: VERSION B CC: 62 y/o M Chief complaint is a short 1-2 statement or word phrase from patient and should be listed in “quotes” “My back is killing me. … it is so bad I can’t think about anything else.” HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts Mr. Newton is a 62-year-old mal patient presenting to the clinic with complaint of acute onset lower back pain of 11/10 intensity. He describes the quality of the pain as sharp, stabbing that radiate to the back of lower extremities with the right side the most uncomfortable. Patient has history of significant moderate intensity chronic lower back pain for 2-3 months. He has a history of high blood pressure and BPH for which he has stopped taking medication he also has history of hepatitis C. He reports that he has not seen a doctor in years. Family medical history is unremarkable. He has a history if intravenous drug use, and cigarette smoking. Onset: Severe lower back pain that started today; moderate mid-back pain for 2- 3 months Location: Mild pain in middle of back; severe pain in lower back pain (L1-3) that radiates to back of legs and more intense in right lower extremity. Duration: Moderate mid-back pain is intermittent. Severe lower back pain has persisted since onset in the morning. Character: Sharp and stabbing pain that is getting worse Aggravating/alleviating factors: Pain gets worse when standing or moving around and unresolved with Tylenol and NSAIDs. Nothing has helped with pain Related symptoms: Pins and needles in the butt area Treatments: Has tried OTC analgesics; Tylenol and Motrin without relief Significance: Pain in mid-back has severity of 3-4 on scale of 1-10 and the lower back pain is as severe as 11/10. Patient cannot walk or cannot think of anything else Review of Systems: (ROS) Use this column to document the ROS below. General: Denies fever, chills or malaise, weight gain or loss. HEENT: Denies headaches, double or blurred vision, hearing problems, pain in ears o sinuses, denies nasal drainage, denies sore throat or difficulty swallowing. Neck/Thyroid: No complaint of any pain or swelling in neck. Pulmonary: Denies SOB, cough, wheezing, or pain on deep breathing CV: Denies chest pain, palpitations, or decreased exercise tolerance GI: Denies nausea vomiting and anorexia. Denies diarrhea or constipations. GU: Denies dysuria or difficulty urinating. Report of oliguria MS: Complains of severe lower back pain, moderate chronic mid-back pain, and weakness in lower legs Heme: No complaints of bruising or frequent epistaxis Endocrine: No complaint polyuria, polydipsia, polyphagia, or heat/cold intolerance. Derm: No complaints of unusual moles, rashes, lesions. Neuro: Reports of tingling and numbness in buttocks. Denies dizziness, seizures or headaches Psych: No complaints of sadness, hopelessness, From the ROS: list/highlight the current symptoms/complaints to generate a list of pertinent “reported or denied” symptoms below: Pertinent positive ROS: Complains of severe lower back pain of severity of 11/10 on scale of 1-10, moderate chronic mid-back pain of severity of 3-4 on a scale of 0-10, and weakness in lower legs. Report of oliguria. Reports of tingling and numbness in buttocks. Pertinent negative ROS: Denies fever, chills or malaise, weight gain or loss. . Case: Sam Newton Case: Sam Newton Date: April 4, 2021 Date: April 4, 2021 or panic attacks. Physical Exam: (PE) Use this column to document the PE below. Vitals Temperature: 98.8-degree F/37.1 degree C Pulse: 102 bpm - regular Blood pressure: 154/96 mmHg - supine/sitting Blood pressure: 152/94 mmHg - upon standing Respiratory rate: 16 bpm SpO2: 98% on room air Height: 5' 10" (178.0 cm) Weight: 205 lbs. (93.0 kg) (BMI 29.4) General: Older male patient with lower pain HEENT: No edema, non-tenderness, lumps or deformities. Normocephalic, atraumatic, face is symmetrical, pupils reactive Neck: No visible scars or deformities of neck, trachea midline Pulmonary: Lungs are clear to auscultation anterior/posterior bilaterally. Chest symmetrical, slightly barrel CV: Tachycardia, elevated blood pressure, normal venous pressure GI: BS normal X 4; Soft with no scars or deformities. GU: Normal external genitalia, no tenderness or urethral discharge, enlarged nontender prostate with right sided nodules From the PE: list/highlight the presence or absence of objective findings to generate a list of pertinent “(+) or (-)” symptoms below: Pertinent (+) PE findings: Tachycardia, elevated blood pressure. Thoracic tenderness of T8-9, lumbar tenderness with diffuse muscle spasm of lower back, lower extremity strength indeterminate due to lack of patient participation secondary to severe pain, and bilateral lower extremities weakness. Enlarged femoral lymph nodes. Saddle paresthesia, gait ataxia, and diminished reflexes on right patella. Enlarged nontender prostate with right sided nodules Pertinent (-) PE findings: Normal bilateral bulk and tone. Range of motion normal and equal bilaterally. Case: Sam Newton Date: April 4, 2021 Based on patient’s age/risk factors, what preventive screening would be recommended at todays or a future visit: • Colorectal Cancer: Screening: adults aged 50 to 75 years • Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults with Cardiovascular Risk Factors: Behavioral Counseling Interventions: adults with cardiovascular disease risk factors • Type 2 Diabetes Mellitus: Screening: adults aged 40 to 70 years who are overweight or obese (BMI > 25) • Depression in Adults: Screening: general adult population, including pregnant and postpartum women (Denies depression) • STI screening (not currently sexually active) Leading/Must not miss Diagnosis Cauda equina syndrome (CES) (G83.4): leading diagnosis due to the saddle paresthesia, ataxic gait, and motor weakness. It is a “must not miss” diagnosis because it is an emergency. Metastatic cancer (C78.1): This a leading diagnosis because it could be the cause of CES. The history of smoking predisposes him for lung cancer. The abnormal PSA and abnormal bone scan are also indicators. Must not miss Diagnosis Spinal epidural abscess (G06.1): Frequently missed because it is rare and the severity of complications if not caught in time Alternate Diagnosis Compression Fracture (S32.02): risk factors for this patient includes history of smoking, age, alcohol use. Disc Herniation (M51.27): Some of the unilateral symptoms makes this a Case: Sam Newton Date: April 4, 2021 • Unhealthy Drug Use: Screening: adults age 18 years or older (Denies any inappropriate drug use) • WeighMorbidity ant Loss tod PrevenMortalitt Obesity iny - RAelatedultsd: Behavioral Interventions: adults Lung Cancer: Screening: adults aged 50 • to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years (USPSTF, 2021) plausible diagnosis but patient denies any heavy lifting. Lumbar strain/sprain (S33.5): Neurological findings in this patient is not typical in this condition. Spinal Stenosis (M48.07): this diagnosis is considered because pain worsens with walking and standing, but the acute onset makes it unlikely. Conclusion Cauda equina syndrome (CES) caused by metastatic cancer is the correct diagnosis (ICD10data.com, 2021) *Case Study Template adapted from the following sources: NP H & P (ReNursing.edu, 2018) and IHuman Patients by Kaplan (2020) Reflective Thinking Exercises 1. History-Taking: Describe your history taking scores and strengths you identified when gathering data. What went well? Also, describe your challenges in gathering data and list areas of your personal needed improvement. Note any missed areas that could be safety issues/errors leading to missed or incorrect diagnosis. Case: Sam Newton Date: April 4, 2021 My interview skills have improved overall, but I still miss a few required. In real life, a patient will be annoyed if they are asked questions that they have already answered. Although some answers were already provided because I did ask the specific questions, I missed points. History taking score for first attempt was 79% and 98% on the second attempt 2. Physical Exam: Describe your physical exam scores and strengths you identified when performing selected exams on your patient. Did you perform an excessive amount of exam items? Did you miss any pertinent exam items identified in the case leading to diagnosis? Note any missed areas that could be safety issues/errors leading to missed or incorrect diagnosis. Physical exam scores are 85%% for the first attempt and 100% for the second attempt. I continue to make improvement in this area. I decided to perform a more comprehensive examination because patient has not had medical care in 5 years. 3. Evidence-based decision making: Discuss the evidence-based resource(s) utilized while seeing the patient. These can be your course readings/IHUMAN lessons/other course info as well as any external articles or supporting literature to help you gain a better understanding of categorizing possible diagnoses in your case. How did you use the symptoms/patient presentation, plus your exam findings, to formulate a differential diagnosis list? What specific feedback from previous case studies has your faculty identified that you plan to incorporate on future cases to avoid pitfalls in data gathering or decision making? What will you do differently to improve? The required text readings from S2D and Dain was very beneficial especially S2D with identifying differential diagnosis. As I get more familiar with the course material, again I do not agree with the experts feedback with the differential diagnosis; spinal neoplasm that I added is not incorrect. References ICD10Data.com. 2021 ICD-10-CM Codes. https://www.icd10data.com/ICD10CM/Codes. Johnson, N. (2018) NP H & P. ReNursingEdu LLC. www.ReNursingedu.com