Case Study

Case Study

CHIEF COMPLAINT

A.J. is a 42 year old single Caucasian female who presents today stating that ""I can't get rid of this darned cough"" which she has had for the past five weeks.

HISTORY OF PRESENT ILLNESS

The patient says that her cough began five weeks ago when she developed a ""cold"" with accompanying symptoms of stuffy nose, cough, and sore throat: all of those symptoms resolved except for a persistent cough. The cough occurs daily and is productive of green sputum. She gets short of breath with minimal exertion and needs to sit down frequently to catch her breath. She thinks she has bronchitis because she had frequent bronchitis as a child. She is requesting antibiotics today because she says her primary care provider always gives her antibiotics for these symptoms. She denies smoking or chest pain. Cold weather seems to be making her symptoms worse and she is no longer able to participate in her weekly exercise regime due to the shortness of breath. She is also now experiencing episodes of being awakened at night by coughing.

PAST MEDICAL HISTORY

Denies any serious illness, no hospitalizations, no surgeries, no transfusions, denies any allergies including allergies to medications, takes no routine medications.

FAMILY HISTORY

Minimal knowledge of family health history but thinks mother had asthma: mother died before age 40 - cause unknown. One brother with allergies. Father unknown.

SOCIAL HISTORY

Works as a CNA in a local nursing home; formerly worked as a prison guard for two years. Lives in an apartment which she shares with her male partner whom she met while working at the prison and where he is still employed. No children but she and her partner have three cats, one dog, a tank of fish, and a newly adopted parrot. Works four days a week for 10 hours each. Awakens at 5 A.M. and gets to bed no later than 10 P.M. most nights. Dietary intake is coffee and breakfast sandwich from Dunkin Donuts on way to work, snack from vending machine of honey bun, lunch of soup and sandwich which she packs the night before, snack of peanuts when she gets home and meat with vegetable and salad if her partner is home for dinner; otherwise, she says she just heats a frozen dinner. Exercise is walking the dog a mile or two each day before and after work.

REVIEW OF SYSTEMS

Positives noted in history given above. Otherwise, negative.

PHYSICAL EXAMINATION

Appears stated age in no acute distress when sitting. No obvious deformities or difficulty communicating.

Vitals: BP 110/70 RR 16 HR 80 T 98.2 Ht. 67"" (5'7"")  Wt. 160lb (72.7kg)

HEENT: All WNL

Cardiovascular: HR RRR; no murmurs or abnormal sounds

Lungs: Expiratory wheezing heard bilaterally in lower lobe

Abdomen: All WNL

 

PROBLEMS LIST

1)    Bronchitis

2)    Persistent mild asthma

3)    Allergic Rhinitis (Hay fever) vs. Sinusitis vs. common cold

4)    Pneumonia with/without pleural effusion

5)    Inadequate sleep due to persistent nocturnal episodes of cough

6)    Dyspnea on exertion (DOE) vs Activity intolerance due to decreased FRC/oxygenation

7)    Persistent cough with sputum x 5 weeks

8)    Ineffective airway clearance due to increased mucus production

9)    Adventitious breath sounds

10) Ineffective therapeutic regimen (history of)

11) Nutritional imbalance

12) Obesity

 

RATIONALE FOR TOP 5 PROBLEMS

�     Asthma vs Bronchitis

o  Asthma: the patient has a persistent cough, expiratory wheezing, shortness of breath with minimal exertion, difficulty sleeping caused by coughing and shortness of breath, and coughing spells which were exacerbated by acute respiratory infection. Patient believes that her mother (died age 40) suffered from asthma. Cold, dry air may trigger asthma flare-ups as well.

o  Bronchitis: the patient has a previous history of bronchitis. She also has productive cough with green sputum, fatigue, shortness of breath and wheezing; all symptoms of bronchitis (Kinkade,2016). Could weather could exacerbate bronchitis and cause symptoms of wheezing, cough, and dyspnea.

�      Allergic Rhinitis (Hay Fever) vs. x Sinusitis vs. Common Cold

o  The patient was previously experiencing stuffy nose and sore throat (since resolved). Her cough, however, has not resolved. The patient's cough is exacerbated by cold weather and accompanied by dyspnea and nocturnal coughing spells; likely from postnasal drip. States that her brother has allergies. The presence of green sputum leads us to suspect the presence a bacterial infection.

�     Pneumonia (With/Without Pleural Effusion): patient has history of multiple bronchial infections as a child. Patient has been trialed on numerous ineffective therapeutic regimens, which could have placed her at a higher right for resistant bacterial pneumonia. The patient is also experiencing wheezing and DOE.

�      Activity Intolerance: patient is unable to participate in her weekly exercise regime due to DOE and decreased FRC. Her lack of restful sleep is likely contributing to her activity tolerance as well.

 References

 Hose, B. Z., Hoonakker, P. L., Wooldridge, A. R., Brazelton Iii, T. B., Dean, S. M., Eithun, B., ... & Carayon, P. (2019). Physician perceptions of the electronic problem list in pediatric trauma care. Applied clinical informatics, 10(1), 113.

 Kinkade, S., & Long, N. A. (2016). Acute bronchitis. American family physician, 94(7), 560-565.

 Wheaton, A. G., Cunningham, T. J., Ford, E. S., & Croft, J. B. (2015). Employment and activity limitations among adults with chronic obstructive pulmonary disease�United States, 2013. MMWR. Morbidity and mortality weekly report, 64(11), 289.

3.    What additional data would you need?

We will need to gather a more extensive patient history while noted a more detailed and thorough physical examination.

Family History (including that of her male partner): try to gather any more information we can about family; presence of obesity, diabetes, heart/lung/kidney disease, blood dyscrasias/anemias, DVT/PE, alcohol or tobacco abuse, military service, job/occupation, disease exposure, mental health etc.

Allergies: any outdoor/environmental allergies? Any medication allergies? Triggers/Reactions/Symptoms/etc.?

Social History: Has she ever been married? revisit smoking history (secondhand smoke via family or male partner?); illicit drug use?; alcohol use? Presence of tattoos (where did she get them)?

Sexual History/OB GYN: Sexual preference/history/activity/contraceptive methods/STI exposure/etc.? Menarche/LMP? Does she has regular or irregular periods? Any problems (e.g., flow, pain, cramping, absence, etc.). Does she see a gynecologist?

Environmental History: History of hazardous exposure? Use or exposure to pesticides? Chemical (e.g., cleaning products) vs environmental exposures (home, work, etc.)? Where does she live (e.g., neighborhood; single apartment vs complex vs mobile home, etc.)? Living conditions of the house (e.g., mold, mildew, etc.)? How often does she was her linens? Clothes? Does she clean the fish tank/bathe pets? Are all of the pets living inside?

Health Maintenance: Has she received the appropriate childhood vaccinations? Adult vaccinations? Further investigate dietary and exercise habits (e.g., sodium intake). Does she have a PCP (and does she regularly see them)? When was the last time she was admitted to the hospital? Does she have insurance/able to pay for medical expenses? Does she have access to health care? Does she have any food insecurities? Does see any eye doctor/dentist/ear doctor? Last visit? Next Visit? Has she ever seen an allergist?

Surgical History: Has she had any childhood surgeries (e.g., tonsillectomy, adenoidectomy, etc.)?

History of Present Illness: How often does she get these symptoms? What does her prescribing physician believe that the problem is? What kind of antibiotics does she normally take (and do they work)? Has she ever experienced the latter symptoms of (persistent and nocturnal) cough and DOE before? Has she in close contact with any sick persons (e.g., family, roommate, NH residents)? Have there been any recent outbreaks of infection or illness at the nursing home where she works? Can she recall any outbreaks or exposures at her prison job (e.g., TB).

Subjective/Objective Health Assessment:  What health problems does she have? What medications is she prescribed? What medications/vitamins/herbs/supplements does she take? Any inhalers or nasal sprays? Has she had any fever, chills, or night sweats? Changes in diet, appetite or weight? Any cognitive, behavioral, psychiatric, or neurological (e.g., memory) problems? Has the patient been getting headaches (e.g., sinus)? Any sneezing or nasal drainage? Problems smelling? Ear aches, tinnitus, or drainage? Hearing problems? Eye problems (e.g., conjunctivitis, edema, lacrimation, skin flaking, burning, visual changes, etc.)? Problems with swallowing, taste, inflammation, mouth lesions/pain, dental infections, postnasal drip, hoarse voice/vocal changes, malodorous breath, etcetera? Any head, neck, or facial trauma? Any chest trauma (e.g., MVA, abuse, etc.)? Any history or presence of chest pain or tightness, jaw pain, back pain, dyspnea, etcetera? History or presence of TB, pneumonia, reactive airway disease, restrictive or obstructive lung disease? Any previous imaging studies (e.g. CXR, CT scan, MRI, CTA, etc.)? History of DVT and/or PE? History or presence of edema? Any JVD, pulsations, hepatojugular reflux, etc.? Chest heaves/dynamic precordium? Any nausea, vomiting, diarrhea, constipation, GERD/heartburn, s/s of bleeding (upper or lower GI), or excessive belching/flatulence? Organomegaly/tenderness? Abdominal masses, dilations, pulsations, lesions, etc.? Any visual clubbing, cyanosis, mottling, or pallor (or history of)? Capillary refill? Presence or absence of body hair? Discoloration of skin (e.g., axillae, neck, ground, legs, etc.)? Numbness, tingling, weakness, paresthesia, tremors, rigidity? What are her hobbies? Does she have insurance? Are her pets seen by a veterinarian (e.g., vaccinations, wellness visits, etc.?

 

Based on case study above:

-What health maintenance activities would you need to consider for AJ? Please include rationale for each."

 

https://www.coursehero.com/tutors-problems/Nursing/30670088-Compare-and-contrast-the-assessment-findings-for-the-following-3/,"Image transcription text

Compare and contrast the assessment findings for the following 3 STD's: for men and women: Chlamydia Genital

herpes Human Papilloma virus HPV"

Comparison of Assessment Findings for Three STDs: Chlamydia, herpes with focus on genital herpes, and human papillomaviruses.

 1. Chlamydia

 Men:

 

 Symptoms: Often asymptomatic. When symptoms occur, they include:When symptoms occur, they include:

 Secretion from the penis (clear or coloured).

 Dysuria (painful urination)

 Testicular pain or swelling

 Complications: Epididymitis, prostatitis, infertility.

 Women:

 

 Symptoms: Frequently asymptomatic. If symptomatic:

 Abnormal vaginal discharge (mucopurulent)

 Dysuria

 Pelvic pain

 A lesion that results in breakage of the uterine lining and leads to bleeding that is not regular is referred as Postcoital bleeding

 Complications: Salpingitis; endometritis; tuberculous peritonitis;chioitis; pericholecystitis; pleurisy; pneumonia; tuberculosis of genitourinary tract; TB meningitis; miliary tuberculosis; tuberculosis arthritis; tubercular lymphadenitis; scrofula; lupus vulgaris; adenoma of stomach; cancer of stomach; perforation peritonitis; pelvic inflammatory disease; ectopic pregnancy; infertility

 2. Genital Herpes (HSV)

 Men:

 

 Symptoms:

 Blisters or lesions in the penis, scrotum or the adjacent skin is another sign.

 Symptoms involving the skin or mucous membranes prior to the development of rash or other manifestations

 Headache during the first wave of the epidemic (fever, weakness, enlargement of lymph nodes)

 Complications: Recurrent flare up, psychological effect, enhanced likelihood of HIV transmission.

 Women:

 

 Symptoms:

 Painful sore or canker on the genitals or around the anus

 Dysuria

 When the mishap occurred a number of times earliest, people experienced flu like symptoms.

 Complications: Recurrent, neonatal transmission at the time of delivery, psychological ramifications.

 3. Human Papillomavirus (HPV)

 Men:

 

 Symptoms:

 Often asymptomatic

 Some of the styling can include genital warts (small, skin-colored, fleshy, or soft, raised or flat skin growths on the penis, scrotum, groin, or anus.

 Complications: Aids the development of cancers of the penis and anus.

 Women:

 

 Symptoms:

 Often asymptomatic

 Genital warts; tiny, hard, pinkish growths typically located on the vulva, vagina, on the cervix or on the arse.

 Complications: Cervical in early stages or cervical cancer, vulvar and vaginal cancers.

 A Summarized Analysis of Differences and Confomities

 Chlamydia: Neither symptomatic in the early stages in men nor in women. Malaise is notable only when symptoms are present and may include discharge and dysuria at times. It is dangerous to pregnancy and childbirth, or to fetal health, particularly for the woman.

 Genital Herpes (HSV): Described by some of the symptoms such as blisters or ulcers that are painful and have repeated occurrences. It has a psychological implication and is strongly linked to HIV risk.

 HPV: May manifest with genital warts but often is without any symptoms. The biggest concern is of cancers, principally cervical cancers in women.