NURS6531 all week discussions latest 2018 September Week 2 discussion Discussion: Diagnosing Integumentary Disorders

Discussion: Diagnosing Integumentary Disorders

When entering examination rooms, advanced practice nurses
often immediately begin assessing patients by looking for external
abnormalities such as skin irritations or cloudy eyes. By making these simple
observations, they can determine how to proceed with their patient evaluations.
During the patient evaluation, advanced practice nurses will use initial
observations to guide them in acquiring the necessary medical history,
performing additional assessments, and ordering the appropriate diagnostics.
The information obtained during this evaluation process will help in the
development of a differential diagnosis. Once a diagnosis is made, the advanced
practice nurse can consider potential treatment options and work with the
patient to develop a plan of care. For this Discussion, consider the following
three case studies of patients presenting with integumentary disorders.

Case Study 1

A 46-year-old male presents to the office complaining of a
pruritic skin rash that has been present for a few weeks. He initially noted
the rash on his feet, but it then spread to between the fingers, his wrist, and
waist. He notes that it does not seem to be on his face or trunk. He recently
came home from a trip to Florida where he had stayed in multiple hotels. He
takes occasional ibuprofen for knee pain, but denies taking other medications
or having other health problems. He has no known drug allergies. The physical
examination reveals a male with several tiny vesicles and scales in between the
fingers, on the feet and ankles, around the patient’s wrist and around the belt
line.

Picture of a hand that is covered in a pruritic skin rash
between the fingers, which covers the wrist. The rash does not uniformly cover
the hand and is scaly in some areas.

NURS6531 all week discussions latest 2018 september Week 2 discussion Discussion: Diagnosing Integumentary Disorders Case Study 2

K.B., a 52 year old Irish American patient who present today
complaining of “a mole” on the skin that is changing colors. He said he has had
this ‘mole’ for almost two years. K.B. is a construction worker currently
residing in Hawaii. As a teen he worked outside and visited the tanning bed
several times a month. He is a worried that this “mole” doesn’t look like the
others on his body.

On your examination, you note, the lesion as round, dark
colored in appearance, and scaly. You also note the mole has an irregular
border and about 0.2cm in size.

Depicted on the skin are four moles. In the center is a
large mole that is dark colored in appearance, with an uneven colored tone,
appears scaly, and has an irregular border. The other three moles depicted
appear normal in appearance.

NURS6531 all week discussions latest 2018 september Week 2 discussion Discussion: Diagnosing Integumentary Disorders Case Study 3

J.V. 50 year old patient with history of eczema is here
today complaining of lesions on the right side of her face and neck. She thinks
it is a flare up of her eczema and is asking for a refill of her ointment, TAC
0.1%.

She complains of some ‘itching’ and a bit of ‘tingling and
pain’ to the lesions. She’s a pharmaceutical worker and thinks that the ‘pain’
maybe due to contaminate exposure. Denies any other associating symptoms. Below
is a photo of the lesions.

Patient presents with lesions on the right side of her face
and neck. The lesions are red in appearance and vary in size. They appear scaly
and do not uniformly cover the entire region of her face or neck.

NURS6531 all week discussions latest 2018 september Week 2 discussion Discussion: Diagnosing Integumentary Disorders

Week 3 discussion

Discussion: Diagnosing HEENT Disorders

In clinical settings, advanced practice nurses may initiate
a physical examination of a patient by examining the components of the HEENT
system. Assessing primary diagnoses and differential diagnoses as they concern
the HEENT system are important in informing your practice in providing optimal
care.

For this Discussion, consider the following three case
studies of patients presenting with head, eyes, ears, nose, and throat
disorders.

Case Study 1

An 86-year-old widowed female is brought to the office by
her daughter-in-law. The patient complains of constant tearing and an itchy,
burning sensation in both eyes. The patient states this is not a new problem,
but it has worsened in the past week and is affecting her vision. The patient
complains that her eyes are dry. She thinks the problem must be caused by one
of her medications. Her patient medical history is positive for hypertension,
atrial fibrillation, and heart failure. She has an allergy to erythromycin that
causes rash and elevated liver enzymes. Medications currently prescribed
include Furosemide 40 milligrams po twice a day, diltiazem 240 milligrams po
daily, lisinopril 20 milligrams po daily, and warfarin 3 milligrams po daily.
The physical examination reveals a frail older female with some facial dryness
and slight scaling. Her visual acuity is 20/60 OU, 20/40 OD, 20/60 OS. The
eyelids are erythematous and edematous with yellow crusting around the lashes.
Sclera are injected, conjunctiva are pale, and pupils are equal and reactive to
light and accommodation.

NURS6531 all week discussions latest 2018 september Week 2 discussion Discussion: Diagnosing Integumentary Disorders Case Study 2

A middle-aged male presents to the office complaining of a
two-day history of a left earache. The onset was gradual, but has steadily been
increasing. It has been constantly aching since last night, and his hearing
seems diminished to him. Today he thinks the left side of his face may even be
swollen. He denies upper respiratory infection, known fever, or chills. His
patient medical history is positive for Type 2 diabetes mellitus, hypertension,
and hyperlipidemia. The patient has a known allergy to Amoxicillin that results
in pruritus. Medications currently prescribed include Metformin 1,000
milligrams po twice a day, lisinopril 20 milligrams po daily, Aspirin 81
milligrams po daily, and simvastatin 40 milligrams po daily. The physical exam
reveals a middle aged male at a weight of 160 pounds, height of 5’8”,
temperature of 98.8 degrees Fahrenheit, heart rate of 88, respiratory rate of
18, and blood pressure of 138/76. Further examination reveals the following:

Face: Faint asymmetry with left periauricular area slightly
edematous

Eyes: sclera clear, conj wnl

L ear: + tenderness L pinna, + edema, erythema, exudates
left external auditory canal, TM not visible

R ear: no tenderness, R external auditory canal clear
without edema, erythema, exudates

+ tenderness L preauricular node, otherwise no
lymphadenopathy

Cardiac: S1 S2 regular. No S3 S4 or murmur.

Lungs: CTA w/o rales, wheezes, or rhonchi.

NURS6531 all week discussions latest 2018 september Week 2 discussion Discussion: Diagnosing Integumentary Disorders Case Study 3

A middle-aged female presents to the office complaining of
strep throat. She states she suddenly developed a sore throat yesterday
afternoon, and it has gotten worse since then. During the night she felt like
she was chilled and feverish. She denies known recent contact with anyone else
who had strep throat, but states she has had strep before and it feels like she
has strep now. She takes no medications, but is allergic to penicillin. The
physical examination reveals a slender female lying on the examination table.
She has a temperature of 101 degrees Fahrenheit, heart rate of 112, respiratory
rate of 22, and blood pressure of 96/64. The head, eyes, ears, nose, and throat
evaluation is positive for bilateral tonsillar swelling without exudates. Her
neck is supple with bilateral, tender, enlarged anterior cervical nodes.

NURS6531 all week discussions latest 2018 september Week 2 discussion Discussion: Diagnosing Integumentary Disorders Week 5 discussion

Discussion: Examining Chest X-Rays

Chest x-rays are an invaluable diagnostic tool as they can
help identify common respiratory disorders such as pneumonia, pleural effusion,
and tumors, as well as cardiovascular disorders such as an enlarged heart and
heart failure. As an advanced practice nurse, it is important that you are able
to differentiate a normal x-ray from an abnormal x-ray in order to identify
these disorders. The ability to articulate the results of a chest x-ray with
the physician, radiologist, and patient is an essential skill when facilitating
care in a clinical setting. In this Discussion, you practice your
interprofessional collaboration skills as you interpret chest x-rays and
exchange feedback with your colleagues.

Consider the three patient case studies and x-rays

Note: By Day 1 of this week, your Instructor will assign you
to post on one of these patient case studies and x-rays:

NURS6531 all week discussions latest 2018 september Week 2 discussion Discussion: Diagnosing Integumentary Disorders Case Study 1

35-year-old Asian male presents to your clinic complaining
of productive cough for two weeks. Stated he has had mild intermittent fever
with myalgia, malaise and occasional nausea.

SH: works as a law clerk

PE: NP noted low grade fever (99 degrees), with very mild
wheezing and scattered rhonchi.

An x-ray film is presented which shows a cloudy lung that
appears slightly distended.

NURS6531 all week discussions latest 2018 september Week 2 discussion Discussion: Diagnosing Integumentary Disorders Case Study 2

This is a 44-year-old Caucasian male being seen at your
clinics with complaints of complaints of cough for 4 days and worsening. Stated
he has had high grade fever. States he feels weak and has been in bed most of
the last two days. Complains of exertional dyspnea, followed by dyspnea at
rest, non-productive cough and pleuritic chest pain

MEDS: Zovirax, Diflucan, magic mouth wash, Zofran,
mycostatin, filgrastin

PMH: HTN, Hep C, HIV/AIDS, thrush

SH: Past IV Drug abuse; lives in a group home;

PE: VS: Ht: 5’7, Wt: 150#, BMI 23,

Anorexic male, febrile, tachypneic, tachycardic, with rales
and rhonchi. You note decreased in breath sounds, dullness, and egophony

An x-ray film is presented which shows petechial markings on
the lungs and which are cloudy in appearance.

NURS6531 all week discussions latest 2018 september Week 2 discussion Discussion: Diagnosing Integumentary Disorders Case Study 3

A 50 year old
Caucasian female presents to the clinic with complaints of cough for almost 2
weeks. Positive productive green sputum with associated chills, sweating, and
fever up to 101.5. She manages a daycare and states that many of the children
have had upper respiratory symptoms in the last two weeks. PMH: DM diagnosed 7
years ago, controlled on medications.

MEDS: Glyburide 10mg qd

PE: She looks ill with continuous coughing and chills.

BP 100/80, T: 102, HR: 110; O2Sat 97% on RA.

Lungs: +Crackles, increased fremitus

Labs: CBC 17,000 cells/mm3 , blood sugar is 120

An x-ray film is presented which shows cloudiness on the
lungs and which also shows some scarring on the lungs.

Week 7 discussion

Discussion: Urinary Frequency

Urinary frequency is a genitourinary disorder that presents
problems for adults across the lifespan. It can be the result of various
systemic disorders such as diabetes, urinary tract infections, enlarged
prostates, kidney infections, or prostate cancer. Many of these disorders have
very serious implications requiring thorough patient evaluations. When
evaluating patients, it is essential to carefully assess the patient’s
personal, medical, and family history prior to recommending certain physical
exams and diagnostic testing, as sometimes the benefits of these exams do not
outweigh the risks. In this Discussion, you examine a case study of a patient
presenting with urinary frequency. Based on the provided patient information,
how would you diagnose and treat the patient?

Case Study 1

A 52-year-old African American male presents to an urgent
care center complaining of urinary frequency and nocturia. The symptoms have
been present for several months and have increased in frequency over the past
week. He has been unable to sleep because of the need to urinate at least
hourly all day and night. He does not have a primary care provider and has not seen
a doctor in more than 10 years. His father died when he was a child in an
automobile accident, and his mother is 79 years old and has hypertension. The
patient has no siblings. His social history includes the following: banker by
profession, divorced father of two grown children, non-smoker, and occasionally
consumes alcohol on weekends only.

Case Study 2

This is a 40 year old Hindu married male complaining of
sudden high grade fever for the last 2 days. He is complaining of right flank
pain with some burning on urination.
PMH: diabetes, HTN. Current meds: metformin 500mg bid, Lisinopril 10mg
QD

Case Study 3

A 52 year old woman presented to the clinic for ongoing
fatigue and weight loss during the last 6 weeks. She thinks she’s loss at least
“10 pounds”. For the past week and a half she’s noted some progressing ‘muscle
cramping’ tetany, as well as ‘tingling’ sensation around her mouth and lower
extremities. She’s also noted some intermittent colicky abdominal pain. On your
exam, you noted a positive Chvostek’s sign. PMH: 20 year history of Crohn’s
disease. She also tells you that she is a practicing vegan.

Week 9 discussion

Discussion: Diagnosing Neurological Disorders

As an advanced practice nurse, you will likely observe
patients who experience neurological disorders. Challenging to the diagnosis of
neurological disorders is the realization that many manifestations of disease
may not be overt physically.

For this Discussion, consider the following three case
studies of patients presenting with neurological disorders.

Case Study 1

80-year-old male Caucasian male brought to the clinic by his
wife concerned about his “memory problems”. Per the wife, she has noticed his
memory declining but has never interfered with his daily activities until now.
He is unable to remember his appointments and heavily relies on written notes
for reminder. Just last week, he got lost driving and was not found by his
family until 8 hours later. He is unable to use his cell phone or recall his
home address or phone number. He has become a “hermit” per his wife. He has
withdrawn from participating with church activities and has become less
attentive.

PMH: HTN, controlled

Prostate cancer 20 years ago

Dyslipidemia

SH: no alcohol or tobacco use; needs assistance with
medications

PE: VS stable, physical exam unremarkable

Case Study 2

A 30-year-old Asian female presents to the clinic with
headaches. History of headaches since her teen years. Headaches have become
more debilitating recently. Describes the pain as sharp, worsens with light and
accompanied by nausea and at times vomiting. Rates the pain as 7/10. Typically
takes 2 tabs of OTC Motrin with ‘some help’. “Sleeping it off in a darkened
room’ helps alleviate the headache. VS WNL, physical exam unremarkable.

Case Study 3

A 50-year-old African American male presents with complaints
of dizziness left arm weakness and fatigue. PMH: poorly controlled diabetes,
hypertension, hyperlipidemia

PE: Upon exam, you noted a very mild dysarthria, he
understands and follows commands very well. Mild weakness on the left side of
the face is noted, and left sided homonymous hemianopsia but no ptosis or
nystagmus or uvula deviation.

Week 10 discussion

Discussion: Examining Endocrine, Metabolic, and Hematologic
Disorders

In the United States, 25.6 million adults age 20 years or
older have diabetes (American Diabetes Association, 2011). If not properly
treated and managed, these millions of diabetic patients are at risk for
several alterations including heart disease, stroke, kidney failure, neuropathy,
and blindness. Proper treatment and management is the key for diabetic
patients, and as the advanced practice nurse providing care for these patients,
it is your responsibility to facilitate this process. Patient education is
critical, as is working with patients to establish a regular pattern for daily
activities such as eating and taking medications. When developing care plans
for patients, you must keep the projected outcomes of treatment in mind, as
well as patient preferences and other factors that might impact adherence to
treatment and management plans. In this Discussion, you draw from your
Practicum Experience and consider factors that impact the education and
treatment of patients with diabetes.

For this Discussion, consider the following three case
studies of patients presenting with endocrine, metabolic, and hematological
disorders.

Case Study 1

An 82-year-old female presents to the office complaining of
fatigue, dizziness, weakness, and increasing dyspnea on exertion. She has a
past medical history of atrial fibrillation, hypertension, and hyperlipidemia.
Medications include warfarin 2 milligrams po daily, lisinopril 10 milligrams po
daily, and simvastatin 10 milligrams po daily. There are no known drug
allergies. The physical exam reveals a 5’2” older female. Her weight is 128
pounds, blood pressure is 144/80, heart rate is 98, temperature is 98 degrees
Fahrenheit, and O2 saturation is 98%. Further examination reveals the
following:

Eyes: + pallor conjunctiva

Cardiac: irregular rhythm. No S3 S4 or M. NO JVD

Lungs: CTA w/o rales, wheezes, or rhonchi

Abdomen: soft, BS +, + epigastric tenderness. No
organomegaly, rebound, or guarding

Rectal: no stool in rectal vault

Case Study 2

A 78-year-old female presents to the emergency room after a
fall 3 days ago. She recently had a right above-the-knee amputation and was
leaning over to pick something up when she fell. She did not want to come to
the hospital, but she is having difficulty managing at home because of the pain
in her left leg where she fell. Her patient medical history reveals RAKA,
peripheral vascular disease, Type 2 diabetes, and stage 3 chronic kidney
disease. Current medications include quinapril 20 milligrams PO daily, Lantus
30 units at bedtime, and Humalog to scale before meals. There are no known drug
allergies. The physical exam is negative and x-rays reveal no acute injuries.
Laboratory studies reveal a normal white blood cell count: Hgb of 8 and HCT 24.
The MCV is normal.

Case Study 3

V.G. is a 47 year old African American male with type 2
diabetes diagnosed two years ago. He is for a follow up and complaining of
increased tingling to the lower extremities. PMH: obesity, dyslipidemia, HTN.
He quit smoking smoking two years ago. Denies any alcohol use. SH: lives with
alone in a subsidized housing. He is a veteran and relies on food stamps and
welfare. Works occasionally. MEDS: he lost his medications and hasn’t taken any
in about a week. His chart indicates his is on Lisinopril 20mg, Januvia 50mg
QD, Lipitor 40mg QD, PE: 5’9, BP: 160/100 RBG: 415.