NRNP6552 Week 8 Case studies

Case 1

A 48-year-old Asian American woman is concerned about thin bones. Her mother was diagnosed with osteoporosis at the age of 50 and fell at the age of 68 and fractured her hip and spent months in Rehab before being able to return home. The patient has no history of fractures.

The patient presents to the office to have her bones checked to see if she has “thin bones”

Patient has no history of previous fractures: Patient states she went through Menopause at the age of 43-44 with no major problems. Patient was diagnosed with hypothyroid at at age 40. Patient does not drink. Smokes 1ppd for 20 yrs. Husband has been out of work for 9 months due to downsizing at his job. Pt works as an administrative assistant for a publisher but does not have health insurance at this time.

Pt had a melanoma removed from her left cheek in 2018; No hospitalizations except for childbirth x2

Family history: Paternal Grandmother died at age 78 due to heart disease. Paternal Grandfather died at age 83 due to heart attack. Maternal Grandmother died at age 82 cause unknown; Maternal Grandfather died from farm accident at age of 56. Mother is 75 alive with Osteoporosis diagnosed at age 50 and HTN diagnosed at age 63. Father is 77 alive with HTN diagnosed at age

45. Pt has two daughters alive and well with no medical problems. Objective Info

Height 5’2’ Wt 105 lbs; BMI 19.2; 128/78; HR-72/min

• HEENT:  Normocephalic, no lumps/lesions

• Neck: supple without adenopathy , no thyromegaly.
• Lungs: Eupneic, CTA
• CV: RRR, no murmurs, rubs or extra sounds noted; 2+ peripheral pulses, no edema noted
• Breast: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge
• Abd: soft, +BS, no tenderness
• MS: Full ROM in spine and shoulders. No tenderness, no spasms

• T-Score is -1.2

Questions

1. What other information do you need

2. What other diagnostic tests would be appropriate for this pt?

3. Is this patient at high risk or low risk? What are her risk factors

4. What other screenings are appropriate for this patient?

5. What is the difference between a Z score and a T score?

6. What would you include in patient education to prevent further loss of bone? Be specific.

Case 2

A 46-year-old Caucasian woman presents to the clinic complaining of breast pain. The patient state the pain is intermittent, in the right breast, the pain is sharp and has a burning sensation. She rates the pain as 7/10 at it worst. The patient states the pain sometimes interferes with her sexual activity. She has tried warm compresses, ibuprofen, and support bras with little improvement. Pt is on oral birth control pills and takes a daily vitamin.

Soc hx: Pt reports she sometimes eats nutritious meals, but due to her job and family obligations she does eat fast food frequently. Pt states she is an assistant accountant at a local accounting firm, which adds to her stress especially at the end of each month and during tax season. She exercises 1-2 times/week by walking around the block. Sometimes the walking causes more pain in her breast. She drinks socially once or twice a month and has 1-2 glasses of wine at that time. She smokes 2 packs/day for last 22 yrs. She has tried to quit but has not been successful. Family history non-contributory.

Objective Info

Height 5’6” Wt 155 lbs; BMI 25; 140/78; HR-72/min

• HEENT:  Normocephalic, no lumps/lesions
• Neck: supple without adenopathy , no thyromegaly.

• Lungs: Eupneic, CTA-bilaterally
• CV: RRR, no murmurs, rubs or extra sounds noted; 2+ peripheral pulses, no edema noted

• Breast: Macromastia breasts are soft, fibrocystic changes bilaterally noted without masses, dimpling or discharge, no redness or inflammation noted.

Questions

1. What other information do you need?

2. Describe the most appropriate way to perform the breast exam on this patient.

3. What diagnostic tests would be appropriate for this pt?

4. What are the risk factors for this patient?

5. What other screenings are appropriate for this patient?

6. When would you refer to a breast specialist?
7. What pharmacological and nonpharmacological therapies would you consider for this patient?

Case 3

A 36-year-old Hispanic woman presents to the OB clinic for her Week 24 check-up, gravida 2 para 1. Patient is a full-time homemaker. Pt states she is doing well but is worried about her weight gain. Obstetric history includes a normal spontaneous vaginal delivery (NSVD) 31/2 yrs ago with a viable 9 lb male infant after a 10-hour labor. No complications during pregnancy, delivery or postpartum period. She denies allergies to food, drugs or the environment. Current meds include Prenatal vitamins 1/day and Fe 90 mg/day. Family history significant only for diet-controlled DM in paternal grandfather and an aunt and obesity in both mother and father.

Objective Info

Height 5’2” Wt 170 lbs; BMI 31.1; 140/84 (sitting); HR-92/min

• HEENT:  Normocephalic, no lumps/lesions
• Neck: supple without adenopathy , no thyromegaly.
• Lungs: Eupneic, CTA-bilaterally

• CV: RRR, soft systolic murmur Grade II/VI, no rubs noted; 2+ peripheral pulses, no edema noted

• Breast: Soft, fibrocystic changes bilaterally noted without masses, dimpling or discharge, no redness or inflammation noted. Breast self-exam reviewed

• GU: Uterus at umbilicus-approximately 24 wks size and non-tender. FHT present with Doppler

Questions

1. What other information do you need?

2. What diagnostic tests would be appropriate for this pt?

3. What are the risk factors for this patient?

4. What other screenings are appropriate for this patient?

5. What management treatment would be most effective for this patient?
6. What are the possible maternal and newborn complications with this health problem?

Case 4

A 32-year-old African American woman presents to the clinic for her 24-week check-up. Pt states her morning sickness has resolved. However, she states she seems sad often and does not understand why, as she is happy about the pregnancy.

HPI: Pt is 24 weeks gestation. The patient is having sad moods at least once a day. She also states she is tired all the time, but figures that is just part of being pregnant, but has no energy and does not feel like doing her usual daily chores. She finds it difficult to go to work every day. This moodiness started about a week ago. She tried going to bed earlier but it did not seem to help. Taking 1 prenatal vitamin every day, No known drug, food, or environmental allergies. Family history is significant only for diet-controlled DM in paternal grandfather with onset in mid 40’s, Mother 58 yrs old is healthy; Father 60 yrs old with hx of DM with onset at age 45 and chronic depression which began in early 20s.

Objective Info

Height 5’4” Wt 147 lbs; BMI 25.2; 132/78 (sitting); HR-88/min

• General: Appears well nourished, hair is in disarray, with flat affect
• HEENT:  Normocephalic, no lumps/lesions
• Neck: supple without adenopathy , no thyromegaly.

• Lungs: Eupneic, CTA-bilaterally

• CV: RRR, soft systolic murmur Grade II/VI, no rubs noted; 2+ peripheral pulses, no edema noted

• Breast: Soft, enlarged, fibrocystic changes bilaterally noted without masses, dimpling or discharge, no redness or inflammation noted. Breast self-exam reviewed

• GU: Uterus at umbilicus- approximately 24 wks size and non-tender. FHT present with Doppler

Questions

1. What other information do you need?

2. What diagnostic would be appropriate for this pt?

3. What are the risk factors for this patient?

4. What other screenings are appropriate for this patient?

5. What management treatment would be most effective for this patient?
6. What are the possible maternal and newborn complications with this health problem?