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 | HUMAN CASE WEEK #4 69 YEAR OLD REASON FOR ENCOUNTER:CHEST PAIN (CLASS 6531)LOCATION jOUTPATIENT CLINIC WITH X-RAY,ECG,AND LABARATORY CAPABILITIES.LATEST CASE 2024 Case acistruicHons a a contained within i is your ‘own, suoent case par wernuCTonS Ene Cane Week | ssieaennaanaicinaca san breni ie oe 2s Sin i re ie i cit Reason for encounter 7 . H po earcies oie enepennemeraeir int teat ee sea eminent “The softmare plats designed to hep you become proficient in the lapnostcreasonig process the steps prio the al diagnos), so {can apply tne process the rea! crc satng. Key o minrnizrg medica evar isthe cical consideration of a broad aerartal ‘Gagnon Set ond he eclecton of tte father ‘nko in” ox hse out hse dagnoses, Case aubor by! unan Patients Academie Fear)  HX Performance Hx Performance You asked 60 unique questions. 26-were key questions/Statemants suggested by the expert case author, You also asked an additional 34 unique quesbons * Missed Questions You dirtn't ask all important questions suggested by the expert author for this case You missed asking 16 of the 42 key questions (Note: Sometimes there is more than one way to get similar information fram yourpatient: Elcuting informatean in more (her one way when inietviewing & patient can be useful } Reason tor Encounter Sx/Sx Characteristics: * How can I help you today? + Woes there 4 popping sensation? + How long does your back pain last? + Have you had the pain in your back trelore? * Any change in your back pain since @ began? * Does anything make the pain in your back betiér or worse? Associated Sx/Sx Characteristics: + Do you teal a tack of coordinatian? + Do you have muscia pam 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  Exams Feedback @ Performed Correctly assess galt & stance 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. auscultate heart » You performed the simulation correctly. e Your dacumentation was correct. blood pressure e You documented pulse pressure, systolicidiastolic, and assessment correctly. © YOu performed the simulation correctly. inspect for muscle bulk and tone In any patient that presents with a clinical complaint of muscle weakness, one should inspect for muscle bulk and tone t get an indication of the possible length of time of the problem and clinical etiology. inspect/palpate back and spine Given that back pain is the patient's chief complaint, a thoraugh exam of the back is required palpate all lymph nodes Lymph nodes should be evaluated when determining the source of possible infection or pain. In the former you are ooking for tendemess and enlargement, In the latter you are evaluating firmness that might be suggestive of malignancy. prostate exam A prostate exam is essential, given a prior history of therapy for enlarged prostate and the acute onset of severe back pain without any clear precipitating event rectal exam Evaluation of rectal tone is always important in individuals with low back pain and any degree of leg weakness. respiration 6 You documented rate, rhythm, and effort correctly. temperature test strength Invany patient that presents with a clinical complaint of muscle weakness, one should assess strength to get an indication of the possible length of time of the problem and clinical etiology.  Missed administer gross pain stimulus » You administered a pain stimulus to a conscious patient. auscultate abdomen ° You didn't listen for at least 5 seconds at RLQ. auscultate lungs e ‘You did not auscultate in the correct order. © You documented left lung and right lung correctly. examine pupils. © YOu Need to examine each pupil at least twice. e You documented left pupil and right pupil correctly. palpate abdomen In a patient presenting with back pain, a full abdominal exam is. critical to took for etiologies that might include referre} pain from internal organs, masses or Vascular issues (€.9.. 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. feflexes - deep tendon The neurologic examination in this patient is a crucial component as abnormalities cannot only determine if there is neurologic impainnent, 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 hemiated disc disease and/or muscle contraction. Exercise #1  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 14/40 morning (1-3); Pain radiation into R>L Gait ataxia RevaTen | a* Saddle parestesia RELATED | Bloat tab ation As Seti) || BELATED Lumbar tenderness/spasm RELATED | saddle paresthesia RELATED Back Pain radiates to right feg RELATED Gaitataxia RELATED _enlarged prostate RELATED | | Leg acahneas bilaterally RELATED Enlarged R femoral lymph node RELATED Tenicanlee RELATED Noncompliance HTN & BP meds RELATED Diminished reflexes on R patelia RELATED tachycardia/Hypertension RELATED Enlarged femoral lymph nodes RELATED 78-13 tenderness RESOLVED PMH Hep C UNRELATED Painful Grimace/reluctance to move RELATED Elevated blood pressure (154/98) 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 tist thal 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 ls important to mentally review the various processes that could be the cause of the pain. in addition, itis important to look at the list of complaints and determine whether they can be grouped into: 1) related findings suggesting a cammon 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 effecti-e. bleed, disk hemiation), 4) fracture (compression fracture due to loss of calcium structure or trauma), or 5) muscle sprain/strain Nest, 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. prostale enlargement and Hep C. Which of these previous conditions might be involved in his current condition? Which ones are nat 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 ts.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 fo the RLE with a "pins and needles” sensation. It has not improved ‘C meds or rest, While he has been unable to participate in all physical exams related to pain, he aiso presents with saddle and leg weakness, gait ataxia, and jumbar spine tenderness/spasms. Additionally, Mr Newton has enlarged femoral lymph nodes and an enlarged/nontender prostate with right-sided nodules. He hasbeen noncompliant with his BPH medication for several years. He is also hypertensive and tachyeardic. Case Problem Statement S. N. is. 62 y/o male who presents with acute onset of severe (11/10) lower back pain thal starled 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, bllateral leg ‘weakness, ataxic gait, saddle paresthesias and bilateral sciatica with standing. Past medical histary and risk factors are: significant for smoking and IV drug use Your Differential Diagnoses Legend: @ Correct X Missed © Extraneous @ cauda equina syndrome (CES) @ compression fracture @ disk hemiation } @ lumbar sttain/sprain @ spinal epidural abscess @ spinal stenosis % metastatic cancer prostate: neoplasm Feedback ® Correct cauida equina syndrome (CES) compression fracture disk hemiation lumbar strain/sprain spinal epidural abscess spinal stenosis onan X Missed ‘You were missing 1 disease that was specified by the case author 1. mefastati¢ tancer Signs and symptoms of metastatic cancer differ based upon the site and type. However, some general findings may include @ Unexplained weight loss © Fever © Fatigue @ Pain Skin changes, €g., excess hair growth, pruritus, erythema, jaundice, hyperpigmentation € Extraneous 1. prostate neoplasm Differential Feedback Differential Ranking  Organize Pa Your Differential Ranking Findings Write @ Correct Problem Statement ‘Differential Your Your Your Diagnosis Lead Graded Alt Graded MNM Graded Select Differentiat ee Diagnosis | Seme | O e ° a e Rank (CES) Differential) | compression : : ® Diagnosis fracture 2 & a ieee «|dee - wnerniation ° ® + a jumbar strainisprain © 2 : q metastatic cancer e ® ° a ® spinal ‘epidural ° © e a e abscess spinal stenosis ° e = o Feedback Cauda Equina Syndrome or neoplastic epidural spinal cord compression (ESCC) Is one ofthe feading diagnoses: The motor weakness, saddle paresthesias and ataxic gait provided the tips that this Is a possibility, The lack of sensory loss is not too: Surprising Since this can be: late finding Metastatic cancer is a possible cause of the ESGC and could be from multiple sources, Our patient has a smoking history which puts him-at risk for lung cancer and his age Increases his risk for multiple myeloma, For both of these malignancies, he lacks many of the clinical stigmata such as: cough, SOB, sputum production or coughing up biood, fatigue, fever, weight loss and generalized bone pain throughout the body. Our patient had none of these complaints, however, rarely malignancies can be occult and thus even without symptoms, metastatic cancer is also a ieading diagnosis, Compression fracture could be due to osteoporosis, This is an alternative diagnosis in our patient due-to his age, smoking, previous poor life-style and high alcohol ingestion However, his Severity of lumbar pain is disproportionate to what is frequently found for this diagnosis and would nof easily explain his neurologic findings, thus it remains an altermative diagnosis, Disk herniation:presents with symptoms: of nerve root compression that is frequently unilateral, occurs following heavy lifiing or pushing. For these teasons, itis an altemative diagnosis. Lumbar strain/sprain is also an altemative diagnosis considering his pain started this morning when getting out of bed and he was noted fo have back muscle spasms. However, his neurologic findings and leg weakness is nof typical for this presentation and thus this remains an alternative diagnosis Spinal epidural abscess. is an abscess focated between the dura mater and the vertebral wall, The bacteria gain access via hematogenous spread or by direct extension from infected fissues such as a vertebral body or muscle. Although this is a relatively rare disease, it does nat present with the classic signs of infection, and thus is frequently missed, Risk factors include: immunosupptession, recent tatiosing, HIV-positive, muscle infection, IV drug use to mention a few. Because this diagnosis is fare, His an aiternstive diagnosis, but remains 3 must-notriss due to the seventy of complications if missed Spinal stenosis can present with worsening pain with standing and walking that tends to get worse: over the years. Our patient's acute presentation with ESGC, a rare complication of spinal stenosis, would suggest an alternative etiology and thus this is-an alternative diagnosis. Selected Tests Feedback: Plan Feedback: Case Plan Management Considerations 1. The treatment goals for ESCO are: = Immediate pain control = Minimization of long term complications + Preservation of neurologic function 2. In selecting the treatment approach, it is important to select measures that are appropriate for: + The patient's burden of disease « Religious and cultural values » Life expectancy Management Plan 1. Pain control a, Glucocorticoids is provided to decrease inflammation b. Pain medications 2. Minimization of long term complications 1, Bed rest to decrease musculoskeletal stress/pain until full evaluation was completed 2. DVT prophylaxis while on bed rest 3. Imaging/pathology evaluation i. Ultrasound guided transrectal prostate biopsy ii, Clinical staging - MRIPET/CT scan ordered as appropriate following biopsy results ii. Selection of appropriate therapy based on stage of disease (once imaging results are known) and religious/cultural values 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 PMHx child/adult illness/hospitalizations/immunizations • No serious childhood illnesses except for common colds, coughs, and stomach pain • Benign prostatic hyperplasia, high blood pressure, hepatitis C. • No hospitalization SurgHx type/when/why/complications • No surgical history FamHx Grandparents (if known)/Parents/siblings/children • No history on grandparents • Both parents were healthy and died from old age • No children SHx Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships • Smoked a pack of cigarette a day for 30 years but quit 5 years ago • History of intravenous drug use (Heroin); he has been clean for 30 years • He has down on alcohol consumption; He used to take 4-5 beers a day, but he has cut down. • Patient works as a environmental cleaning car driver Reproductive Hx Female: Age of menarche/menstruation cycle duration/gravida para status/Childbirth hx/sexual hx and concerns/LMP/menopause Breast/cervical screening (if any) Male: Sexual hx and concerns/issues with fertility (if any)/Testicular or prostate screening (if applicable) Screening for STI’s (if applicable) • Patient refused to answer question about STDs • He reports he is heterosexual Allergies (Food, Drug, Environmental, etc.) • NKA List of Medications/supplements (prescription, OTC, complementary alternative therapies) • Tamsulosin (Stopped taking it 5 years ago) • BP medication (Stopped taking it 5 years ago) • Tylenol • Motrin Case: Sam Newton 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. Date: April 4, 2021 MS: Normal bilateral bulk and tone. Range of motion normal and equal bilaterally. 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. Lymph: Enlarged femoral lymph nodes Derm: Skin warm, dry. Hair and nails normal. Skin color appropriate for ethnicity. Neuro: Saddle paresthesia, gait ataxia, diminished reflexes on right patella Psych: Appropriate speech, judgment, cooperative. • Unhealth y Dru g Use : Screening : adult s ag e 1 8 year s o r olde r (Denies any inappropriate drug use) • Weigh Morbidity an t Los s t o d Preven Mortalit t Obesit y i n y - R A elate dults d : Behaviora l Interventions : adult s Lung Cancer: Screening: adults aged 5 0 • to 80 years who have a 20 pac k - yea r smoking history and currently smoke o r have qui t withi n th e pas t 15 year s (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. 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.co m Kaplan, Inc. (2020). Case study: Emma Ryan. IHuman patients by Kaplan. Case: Sam Newton Date: April 4, 2021 United States Preventive Services Taskforce (2021). A and B Recommendations: United States Preventive Services Taskforce. A and B Recommendations | United States Preventive Services Taskforce. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-and-b-recommendations.