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103 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE James is a 5‐year‐old male who presents to his pediatrician after being seen in the emergency room 2 days prior for hives and trouble breathing after eating a peanut butter and jelly sandwich. His mother reports that James has had peanut butter before and would occasionally cough but has never had any skin changes that she can remember and certainly never had trouble breathing. She wonders whether he was choking on the peanut butter instead of having an allergic reaction but concedes that he turned red and was gasping for breath. He was also found to have hives all over his back and trunk. “No one in our family has a peanut allergy and it's basically all that his older brother eats. It would be a real problem if we couldn't have it in the house. ” The provider explains to the mother that James recovered from his episode after receiving a dose of epinephrine, which would not have helped if he was choking, and hives are not caused by simply coughing. The pro-vider asks if James has had any peanuts since the incident and mother says “no. ” James has also not had any further episodes of hives or respiratory distress since being discharged from the hospital. His mother grudgingly agrees that it probably wasn't choking, but asks “Are you sure that this was an allergy? Could we get him tested or something? What do we in the meantime?” She holds up the Epi Pen that she was given at the hospital: “I don't want to carry this around all of the time and James isn't old enough to know how to use it. ” Birth history: James was born via normal, spontaneous vaginal delivery at 42 weeks. He weighed 10 lbs, 1 oz. He did not spend any time in the neonatal intensive care unit (NICU) and was discharged to home with his mother at 2 days of life. Social history: James lives with his mother, father, 8‐year‐old brother (Kevin), and 1‐year‐old sister (Kyla). James attends full‐day kindergarten at a local public school. The family has 2 cats and a fish. Diet: James is considered “overweight” by BMI, but is an active child with a lot of muscle. He plays soccer in the fall and baseball in the spring and summer. He has a total of 1 hour of recess per day at school. He eats a variety of foods, including grains, fruits, andvegetables, and his main protein sources are peanut butter and chicken. He drinks 8 oz of juice per day and about 12 oz of milk per day. Case 4. 10 Food Allergies By Allison Grady, MSN, APNP | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
104 The School-Aged Child Elimination: James has no history of constipation and no history of urinary tract infection (UTI). Sleep: James has an inconsistent bedtime routine, but generally goes to bed around 8 p. m. on school nights and wakes up at approximately 6 a. m. On the weekends, he is often up until 10 p. m. but still wakes up around 6 a. m. Family medical history: James's father has lactose intolerance and James's mother has a history of eczema. Maternal grandmother: history of breast cancer (still living); paternal grandmother: hypertension (on medications); maternal grandfather: prostate cancer (still living) and Type 2 diabetes; paternal grandfather: deceased from heart attack at age 62; maternal aunt: history of celiac disease; paternal aunt: history of hypothyroid; paternal uncle: history of depression. Medications: James does not take any medications. Allergies: James has no known drug allergies but may have a peanut allergy. OBJECTIVE Vital signs: Heart rate is 110; respiratory rate is 13; oxygen saturation is 100% on room air; blood pressure is 98/62. Denies any pain. General: Well‐appearing 5‐year‐old child, appears masculine in dress and manner. He is in no distress. HEENT: Normocephalic head with no appreciable lumps or bumps. Eyes demonstrate ability to fix and focus, pupils are equal, round, and reactive to light. Ears are set proportionately to head. Tympanic membranes are visible with no evidence of infection (no pus/fluid/erythema). Trachea is midline. Thyroid is appropriate in size. Mucous membranes are moist. Dentition demonstrates 1 loose tooth and 1 missing tooth. All primary teeth at this time. Cardiovascular: Regular heart rate and rhythm. No rubs, murmurs, or gallops heard. Respiratory: Lungs clear to auscultation in all fields. No wheezes, rhonchi, or rales. Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds are present in all four quadrants. Gastrointestinal/Genitourinary: Deferred. Neurological: Grossly intact. Demonstrates grossly normal hearing, vision, balance. No abnormal gait observed. Musculoskeletal: All 4 extremities move equally with appropriate strength and range of motion. Skin: Color is appropriate for race; no pallor. No rashes or hives noted. Patch of mild eczema on left lower extremity. Temperature and texture otherwise within normal limits. CRITICAL THINKING What are the top three differential diagnoses? What testing will confirm the diagnosis? How should the provider educate the mother about the seriousness of anaphylaxis and the risk of it occurring again? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Food Allergies 105 How can the provider help the school manage a child with food allergies? If this family does not have insurance, what is the expected out‐of‐pocket expense for an Epi Pen? Likely more than one will be needed, so how can a family navigate this barrier? What is the essential information that all caregivers (not just parents) need to know when caring for James? What advice should the mother be given regarding introduction of peanut‐based products to the youngest child now that food allergies are known to be in the family? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
107 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Tamika, a 12‐year‐old girl, came to the community health clinic with her mother, who had requested an urgent appointment to discuss a note from Tamika's physical education teacher with her nurse practitioner (NP). The note stated that Tamika was having difficulty keeping up with her class-mates because she became short of breath when participating in activities. Tamika denies any other episodes of shortness of breath but reports that she occasionally has to stop and rest when climbing stairs. She has no persistent cough, wheeze, or seasonal allergies. She reports that she has not yet had a period. Diet history: Tamika seldom eats breakfast at home and occasionally will eat cereal from the school breakfast. For lunch she likes pizza or macaroni and cheese but does not eat if these items are not on the school menu. She arrives at her grandmother's house around 3:30 p. m. and has a salty snack and a soda. She eats dinner with her father, either at home or at a local fast‐food restaurant. Sleep history: Tamika's mother notes that she snores loudly and sometimes awakens at night. She is currently not taking any medications. Past medical history: Tamika was born after 36 weeks' gestation to a 39‐year‐old mother. She weighed 4 lb 14 oz; and, in addition to being preterm, she was small for gestational age. Her mother smoked 1/2 ppd. Her neonatal history was unremarkable, and she was discharged at 1 week of age weighing 5 lb 2 oz. She was formula fed. Her past medical history is otherwise unremarkable except for treatment on 2 occasions for right otitis media at ages 1 and 5 and for day surgery at age 18 months to repair a bilateral inguinal hernia. There were no complications. She has no history of respiratory illness, asthma, or allergy. Family history: Positive for Type 2 diabetes in Tamika's maternal grandmother. Her father is positive for cardiovascular disease and had a mild heart attack at age 48, has high blood pressure, and takes statins for elevated cholesterol. Her maternal grandfather died at age 42 from a heart attack and diabetes. Her paternal grandparents are reportedly alive and well and are living in Puerto Rico. Case 4. 11 Obesity By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
108 The School-Aged Child Social history: Tamika is in sixth grade. She is seldom absent and frequently makes the honor roll. She says she likes school but notes that she is shy and has few friends. She does not take part in any extracurricular activities and spends her after‐school time helping her grandmother cook or watching TV. She likes to read. She denies ever using tobacco products, drugs, or alcohol. She admits to feeling sad and lonely at times but denies ever wanting to injure herself. She likes her parents but says they don't always understand her or have time to talk to her. Tamika lives with both parents in a 2‐bedroom, third‐floor apartment near her school. Her father is employed as a laborer, and her mother works for a cleaning service 5 evenings a week. The family has a stable income. Tamika has 3 older siblings, ages 17, 19, and 21, living outside of the home. Her maternal grandmother lives nearby, and Tamika often goes to her home after school. Both parents were smokers previously but stopped 5 years ago. They moved to this area from Puerto Rico 20 years ago. Both speak fluent English. OBJECTIVE General: Tamika is a 12‐year‐old, Hispanic female who is neatly dressed and cooperative. Vital signs: She is 5 feet tall and weighs 174 pounds. Her blood pressure is 116/70, pulse is 74, and respirations are 16 breaths/minute. Temperature is normal. HEENT: PERRLA; EOMs intact. Oral pharynx is positive for 3+/4 tonsils, without lesions or exudate. No dental caries are noted. Neck: Supple with full range of motion. No lymphadenopathy is present. Respiratory: Her lungs are clear bilaterally with no wheezes, rales, or rhonchi. Cardiac: Normal sinus rhythm with no murmur or irregular beats. Chest: Breast buds are present bilaterally, with no tenderness or discharge. Abdomen: Soft but protuberant with no masses or hepatosplenomegaly. Normal bowel sounds are heard in all 4 quadrants. Neuromuscular: Back is straight with no curvature noted on forward bend. She has full range of motion in all extremities. Reflexes are normal. Skin: Clear except for darkly pigmented areas on her neck. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___BMI___Oral glucose tolerance test (OGGT)___Insulin resistance___Cholesterol screen___Sleep study___Psychosocial evaluation | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Obesity 109 What is the most likely differential diagnosis and why? ___Sleep apnea___Obesity___Insulin resistance___Type 2 diabetes___Exercise intolerance___Psychosocial issues Are any referrals needed at this time?Can the school be of assistance?What community resources are available to this family?What type of nutrition support may aid this family? NOTE: The author would like to acknowledge Elaine Gustafson, MSN, PNP, who co‐authored this case in the first edition of this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Section 5The Adolescent Case 5. 1 Drug Use 113 By Anna Goddard, Ph D, APRN, CPNP‐ PC Case 5. 2 Weight Loss 115 By Anna Goddard, Ph D, APRN, CPNP‐ PC Case 5. 3 Menstrual Cramps 119 By Vera Borkowski, MSN, APRN, FNP ‐C Case 5. 4 Missed Periods 121 By Vera Borkowski, MSN, APRN, FNP ‐C Case 5. 5 Birth Contr ol Decision‐Making 123 By Jessica Chan, MSN, APRN, PPCNP‐ BC Case 5. 6 Vaginal Dischar ge 125 By Betsy Gaffney, MSN, APRN, FNP ‐BC Case 5. 7 Sexual Identity 127 By Betsy Gaffney, MSN, APRN, FNP ‐BC Case 5. 8 Knee Pain 129 By Jessica Chan, MSN, APRN, PPCNP‐ BC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
113 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Natalie is a 17 year‐old female who presents to the school‐based health center (SBHC) for the fourth time in 1 week with nonspecific complaints. Several teachers have reported Natalie falling asleep in class and “thinks she might be on drugs. ” Her grades have continued to decrease this semester from C averages to barely passing most of her classes. Natalie reports she is tired “all the time” even though she claims to sleep 8-10 hours a night. She reports frequently waking up and not being able to fall back asleep. She does not like school and states “I don't need anything I am learning in school. ” When offered the PHQ2 and CRAFFT to complete as part of routine screening, she refused to complete both of them. She is requesting to be sent home. Past medical history: Natalie was hospitalized once as an infant with wheezing and bronchitis. She reports no primary care provider and receives care at minute clinics, emergency rooms, or urgent care when needed. Family history: Natalie's mother has fibromyalgia, depression, and chronic headaches. Father's history is unknown. Social history: Natalie lives in a single‐parent household with her mother. No siblings live at home but she has half‐siblings who are no longer living at home; one is incarcerated and one has unknown whereabouts. Natalie has previously had detention for marijuana possession and has been caught juuling in class. Her grade averages are Ds and Fs and she is not on‐track to graduate this year. She admits to occasionally drinking with friends after school but has never blacked out and denies getting in the car while intoxicated. Natalie currently has a boyfriend but “it's nothing serious” and has also been involved with females. Psychiatric: Natalie has no history of a known diagnosis of trauma, depression, anxiety, or sub-stance use disorder. Medications: Natalie has a previous prescription for Lexapro 10 mg but reports “it wasn't working” so she stopped taking it. The previous prescribing provider for Lexapro and age of treatment is unknown. She denies vitamins, supplements, or over‐the‐counter medications. Allergies: Natalie has no known drug allergies (NKDA). Case 5. 1 Drug Use By Anna Goddard, Ph D, APRN, CPNP‐PC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
114 The Adolescent Review of systems: Natalie denies problems with weight gain or weight loss, fever, night sweats, or pain. She has no difficulty in hearing, runny nose, post‐nasal drip, or ear pain. She denies history of cardiovascular issues, shortness of breath, night sweats, prolonged cough, wheezing, or gastro-intestinal issues. OBJECTIVE General: Natalie is dressed in leggings and an oversized sweatshirt with her hair in a ponytail, typical of adolescents. Vital signs: Temperature: 98. 8°F; heart rate: 70 beats per minute; BP: 118/60. EENT: PERRLA, EOM intact, normal mucosa, no nasal discharge, swollen turbinates, tonsils 1+ with no exudate. CV/Respiratory: Normal rate and rhythm. Lungs clear to auscultation with no wheezing and crackles. Abdomen: Bowel sounds normal. CRITICAL THINKING What are the most likely differential diagnoses in this case and why? __Substance use/abuse__Alcohol use/abuse__Depression__School phobia__Sleep problems__Thyroid disorder What are the top diagnostic tests required in this case and why? __Toxicology screen__Complete blood count (CBC) with differential__Complete metabolic panel (CMP)__Thyroid panel__Suicide assessment What are the concerns at this point?What is the plan of treatment?What are the plans for referral and follow‐up care?What health education should be provided to this patient?Natalie asks, “Are you going to tell my mom about this?” How do you respond?Does the patient's psychosocial history impact how you might treat her?Can minors seek substance abuse counseling without parental consent?Are there any standardized guidelines that should be used to treat this case? If so, what are they? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
115 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Roseanne is a 15‐year‐old female who presents to the adolescent clinic with her mother for her annual wellness examination. Her mother reports she is “concerned with Roseanne's weight. ” Specifically she reports that Roseanne needs to “make weight for cheerleading competition. ” Roseanne is well‐groomed, polite, and working on homework while the health care provider speaks to her mother. Her last physical examination was at the School‐Based Health Center from a previous school she attended and was reported by her mother to be normal. Past medical history: Roseanne has a history of a right ankle fracture from 2 years ago, treated with physical therapy and reported complete healing. Roseanne has also a history of right broken forearm and wrist injury from a previous cheerleading injury. She was hospitalized after both previous bone breaks, both requiring surgery. She reports no pain currently. Menarche occurred at age 13 and Roseanne reports that periods were monthly at first and then she started missing periods or having them sporadically. She is now on a triphasic birth control and reports she no longer gets her periods, which she likes because she is a competitive cheerleader and doesn't have to worry about her monthly menstruation while she is cheering. Family history: Father is a Type 1 diabetic and has hypertension. Mother has history of anxiety and post‐traumatic stress disorder (PTSD). Maternal and paternal grandparents are deceased. No siblings. Social history: Roseanne lives in Dallas and moved to a new district with a “better cheerleading squad” in hopes of winning the district championship this year. Roseanne reports that she gets along well with her family and gets all As and A+s. She has friends at her new school and reports she enjoys cheerleading as “it is her life. ” Roseanne's mother reports that she has a chance for cheer‐captain her senior year. Roseanne runs every day before school at 6 a. m. and then has cheer-leading practice every day after school from 4:00-6:30 p. m. She competes and has football or bas-ketball games almost every weekend. She studies and completes her homework from the time she gets home from cheerleading practice until 11 or sometimes 12 at night, when she then goes to bed. Medications: Occasional ibuprofen for sore muscle aches and strains. Case 5. 2 Weight Loss By Anna Goddard, Ph D, APRN, CPNP‐PC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
116 The Adolescent Allergies: NKDA; no allergies to foods or environment. General: Denies fever, chills, or malaise. Denies restriction in food or decreased appetite. Skin, hair, nails: No pigment changes, no current rashes although occasional tinea from tumbling on gymnastic mats; occasional bruises from cheerleading falls and acrobatics. HEENT: Denies difficulty with hearing, sinus problems, runny nose, postnasal drip, tinnitus, mouth sores, teeth, ear pain, or sore throats. She reports “doesn't have time to be sick. ” Cardiovascular: No history of irregular heartbeat, chest pains, swelling of feet or legs. No history of murmurs. Respiratory: No shortness of breath, night sweats, prolonged cough or wheezing. Gastrointestinal: No heartburn, constipation, diarrhea, constipation, nausea, vomiting, or blood in stools. Genitourinary: Unremarkable. Musculoskeletal: Occasional joint pain and aching muscles: relieved with Icy‐ Hot ointment, icing, and over‐ the‐counter Motrin; occasional shoulder pain and joint swelling after competi-tions from certain tumbling and basket catches: treated by physical therapy and over‐ the‐counter Motrin. Hematologic: Does not “bruise easily” but does bruise from heavy athletics dance tumbling; no history of unknown swelling. OBJECTIVE General: Muscular teen dressed in athletic pants and tank top. Interactive and appropriate with provider and mother. Vital signs: Height: 63 inches; weight: 100 lbs; BMI: 17. 7 (6th percentile); BP: 92/61; HR: 52; RR: 16. Skin: Bruising around both knees and shins; skin warm, dry, with sporadic mild acne covered by make‐up. HEENT: Normocephalic, +PERRLA, TMs gray and visible ossicles; intact, moist mucous mem-branes; nares patent; oropharynx clear. Neck: No lymphadenopathy. Cardiovascular: Regular rate and rhythm; no murmur; femoral pulses equal. Respiratory: Lungs clear bilaterally. Breast: Tanner IV symmetrical. Abdomen: Flat, soft, nontender, muscular. Genitourinary: Tanner stage IV. Musculoskeletal: Full range of motion ×4 extremities; no pain or swelling, back straight; muscular. Neurologic: Cranial nerves II-XII grossly intact, steady gait and balance; reflexes +2 and equal. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Weight Loss 117 CRITICAL THINKING What are the top differential diagnoses in this case and why? ___Eating disorder___Excessive exercise___Malnutrition___Malabsorption___Thyroid disorder___Anxiety___Female athlete triad What are the diagnostic tests required in this case and why? __Urine pregnancy test___Glucose___Urinalysis___CBC with differential___Thyroid panel___Prolactin level___Electrolytes What are the concerns at this point?Should Roseanne's mother be asked to leave the room at this time? Why or why not?What is the plan of treatment?What are the plans for referral and follow‐up care?What health education should be provided to this patient?What demographic characteristics might affect this case?Are there any standardized guidelines that should be used to treat this case? If so, what are they? If this patient was male (instead of female), how would that change management and/or treatment? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
119 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Khaleesi is a 16‐year‐old who comes to the school‐based health center (SBHC) after she just got her period in school. She is requesting a pad or tampon from SBHC because “I'm embarrassed . . . I soaked through my clothes. ” Khaleesi says she usually misses “about 1 or 2 days each month because of my period. ” While checking the patient into the electronic health system, it is noted her school absences are high. She reports she's gotten her period since age 11, every month, but once she got it twice in one month. She uses 6 pads or tampons on the heaviest days, but her period usually only lasts about 5 days. She says her cramps, “aren't too bad usually, but sometimes I will throw up when they are really bad. ” She reports “I think my mom gives me Advil some-times?,” but she does not use medication every period, and “it only helps sometimes. ” Khaleesi denies any urinary frequency, urgency, dysuria, hematuria, vaginal discharge, pruritus, lesions, or lower abdominal pain other than “my normal cramps. ” Past medical history: Tonsillectomy and adenoidectomy around age 8; seasonal allergies. Family history: Khaleesi's mother and aunts with heavy periods. Social history: Denies drug, alcohol, or vaping use. Denies any sexual activity (oral, anal, or vaginal) current or in past. Medications: Zyrtec 10 mg only in springtime for allergies. Allergies: NKDA, no food allergies. OBJECTIVE Vital signs: Height: 61 in; weight: 122 lbs; BP: 118/68; HR: 80; RR: 12; BMI: 23. Pain 5/10 on numeric scale, lower abdominal. Patient Health Questionnaire‐2 = 0 negative screening. General: Pleasant, well developed, well nourished, in no acute distress. Respiratory: CTA bilaterally, no wheezes, rales, or rhonchi. Case 5. 3 Menstrual Cramps By Vera Borkowski, MSN, APRN, FNP‐C | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
120 The Adolescent Cardiac: RRR, S1 S2 normal with no murmurs, rubs, or gallops. Breast: Tanner V symmetrical. Abdomen: Bowel sounds present, abdomen soft, nontender, nondistended with no hepatosplenomegaly. Genitourinary: Pubic hair; Tanner V normal female; + menses. CRITICAL THINKING What is the most likely differential diagnosis and why? ___Dysmenorrhea___Endometriosis___Pelvic inflammatory disease (PID)___Urinary tract infection (UTI)___Appendicitis___Pregnancy—threatened abortion___Pregnancy—ectopic Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Pelvic and transvaginal ultrasound___CBC with differential___CMP___Urine pregnancy test___Pelvic exam with cervical swab for GC/CT What questions would you ask Khaleesi about her menstrual cycle?What additional information/questions are needed?What is the plan of treatment?Are there other options?Is it common for teen girls to miss school because of their periods?When should she be seen for follow‐up?What health education should be provided to this patient?Are there technologies available to assist this patient in her care? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
121 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Genevieve is a 17‐year‐old female who came to the clinic requesting a pregnancy test “because I haven't gotten my period and it is 3 weeks late. ” Genny reports that she normally gets her period every month and uses a period tracker, and is able to report her last period's exact start date 55 days ago. She reports that her last period was of normal duration and flow. She says she had multiple occurrences of unprotected sex with her boyfriend of the same age in the past month, and has not taken any pregnancy tests at home. Per her chart and report, Genny has not previ-ously been screened for sexually transmitted infections (STIs). She states, “We lost our virginity to each other a few months ago, so I don't think he has any STIs. ” The clinician asks her if she wants to get pregnant and Genny states, “Not really, but my boyfriend doesn't like using condoms. ” Genny has not told her family she is sexually active, and is requesting that this visit be confidential. She is not on any type of birth control, “because I'm afraid if I ask, my mom will know I'm having sex. ” Past medical history: Obesity. Family history: No pertinent family history. Social history: Denies substances, alcohol, or vaping use. Scores negative on PHQ‐2 screening. Reports only vaginal intercourse in a monogamous relationship. 1 sexual partner. Medications: None. Allergies: NKDA OBJECTIVE Weight: 210 lbs; height: 65 in; BMI: 34. 9; BP: 110/70; PHQ‐2: 0 Negative. General: Pleasant, well developed, obese, in no acute distress. Respiratory: CTA bilaterally, no wheezes, rales, or rhonchi. Case 5. 4 Missed Periods By Vera Borkowski, MSN, APRN, FNP‐C | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
122 The Adolescent Cardiac: RRR, S1 S2 normal with no murmurs, rubs, or gallops. Breast: Tanner V symmetrical. Abdomen: Bowel sounds present, abdomen soft, nontender, nondistended, with no hepatospleno-megaly. Exam limited by adipose habitus. Genitourinary: Pubic hair normal; Tanner V normal female; mucosa pale and pink, no lesions; no lymphadenopathy, discharge, or odor. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Urine HCG___HIV testing___STI screening___Pap smear___Urine dipstick Why is it important to ask Genny what she feels her boyfriend would want if she were pregnant? What additional questions should Genny be asked?If Genny is pregnant today, what are her options?Should contraception be prescribed today?What health education should be provided to this patient?Are there technologies available to assist Genny in managing or understanding her menstruation? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
123 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Lauren is a 17‐year‐old female who presents alone to the primary care office to discuss birth control options. She has been in a relationship with her boyfriend for 6 months and is currently sexually active with only him. She has a history of 1 partner prior to her current boyfriend. She reports using condoms always and never having unprotected intercourse. She has not discussed this with her mother yet, but does think she could be open about it. She has not had testing in the past for sexually transmitted infections (STIs), but would be interested and denies symptoms such as abnormal vaginal discharge, dysuria, pelvic pain, or any new rashes or lesions. She is due for her menses in 3 days. She generally has cramps the day before and the first day of her menses, and takes ibuprofen with good effect. Past medical history: Lauren has a history of eczema and seasonal allergies. Family history: Lauren's biological mother has a history of dysmenorrhea. Social history: Lauren lives at home with her mother, father, and younger brother. She is in the 12th grade and plays tennis for fun. She reports having many good friends and denies sub-stance use. Medications: Lauren's medications include cetirizine (Zyrtec) 10 mg daily during allergy season and occasional triamcinolone cream for her eczema. Allergies: NKDA. OBJECTIVE General: Well appearing, no acute distress Vital signs: Weight: 145 lbs; height: 62 inches; BMI: 26. 5; HR: 72; B/P: 116/74. Cardiovascular: Regular rate and rhythm. S1/S2 normal. Respiratory: Lungs clear to auscultation bilaterally. Case 5. 5 Birth Control Decision ‐Making By Jessica Chan, MSN, APRN, PPCNP‐BC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
124 The Adolescent Breast: Tanner V breast development noted. Not palpated at time of visit; at last annual physical exam had normal breast exam with no masses. Gastrointestinal: Bowel sounds normoactive in all four quadrants. Soft, nontender, nondistended, with no hepatosplenomegaly. Genitourinary: External exam with Tanner V pubic hair development noted and no lesions present. CRITICAL THINKING Given the information provided, what other questions would you ask? What diagnostic or screening tests would you consider running on this patient? ___Urine pregnancy test___Beta pregnancy test (serum h CG level)___Urine gonorrhea and chlamydia (GC/CT)___Serum HIV immunoassay and RT‐PCR (viral load)___Serum RPR (reactive plasma reagin) or VDRL (Venereal Disease Research laboratory) testing for syphilis___Pelvic exam with wet mount___Pap smear___Complete blood count (CBC)___Lipid panel (baseline cholesterol screening) What are the concerns at this point?What is the diagnosis at this point?What types of contraceptives should be considered for Lauren?How would each contraceptive option be initiated?What are some common contraindications to contraceptives?How should Lauren be counseled about side effects?What are the plans for referral and follow‐up care?What other education should Lauren be provided with related to reproductive health?If the patient chooses not to discuss her choice to seek out birth control options with her mother, how would you proceed? Are there any standardized guidelines that should be used to treat this case? If so, what are they? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
125 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Nora, an 18‐ year‐ old college student known to this family practice office, presents with a com-plaint of “some spotting since my last period and a vaginal discharge. ” Nora is home on a college break and states “I'm afraid I have an STD. ” She relates that she has “been healthy” while at school “except for this problem” and that she “did not feel comfortable going to the university health center. ” She denies any urinary burning or frequency. She denies any abdominal pain or pain with sex. Past medical/surgical history: Negative with exception of tonsillectomy, age 7. Medications: None. Allergies: No known allergies. Menstrual history: Menarche age 10 with regular 28‐day cycle with 3-5 days of bleeding. Last menses 3 weeks ago with intermenstrual spotting 2 times since then. Sexual history (obtained using the CDC's “5 P” approach): Partners: Nora's first sexual encounter was at age 16. She has had 4 encounters in the past 2 years with 2 differ ent partners, with 2 encounters in the last 2 months. Prevention of pr egnancy: Nora was prescribed a triphasic oral contraceptive at age 16 but says “I stopped taking it after a few months and haven't been on any since. ” Her partners “use con-doms once in a while. ” Prevention of STIs: Limited to inconsistent condom use. Practices: Nora describes her encounters as limited to vaginal intercourse and “oral sex once in a while. ” She denies anal sex. Past history of STIs is negative. Case 5. 6 Vaginal Discharge By Betsy Gaffney, MSN, APRN, FNP‐BC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
126 The Adolescent OBJECTIVE General: Anxious 18‐year‐old female in no acute distress. Well groomed with good hygiene. Cooperative. Vital signs: Height: 5 ft 4 inches; weight: 112 lbs; BMI: 21. 2; temperature: 97. 8°F; B/P: 118/72; HR: 98. Respiratory: Normal respiratory effort, CTA bilaterally. Cardiac: Regular rate, rhythm. No murmurs, gallops. Breasts: Tanner IV. With Nora's consent a pelvic exam was done. Pelvic/Genital exam: No vulvar or vaginal lesions. Mucoid, nonodorous discharge was noted and vaginal and endocervical swabs obtained. Cervix appeared inflamed but was nonfriable and there was no cervical motion tenderness (CMT). Discomfort but no tenderness on bimanual examination. CRITICAL THINKING Which diagnostic studies should be considered to assist with or confirm the diagnosis?___Urine HCG___Nucleic acid amplification test (NAAT) for chlamydia___NAAT for gonorrhea___Wet mount (saline, KOH prep of vaginal secretions) to rule out coexisting infection___HIV‐1 antibody testing___Venereal Disease Research Laboratory (VDRL) What is the most likely differential diagnosis and why? ___Chlamydia (C. trachomatis)___Gonorrhea (N. gonnorhoeae)___Bacterial vaginosis___Trichomonas vaginalis___Pregnancy___HIV What is the plan of treatment?How should this patient be counseled regarding the prevention of STIs?Is this patient at risk for HIV?Should this patient be retested for cure after treatment?Should this patient's partners be treated? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
127 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Michelle, a 17‐year‐old Caucasian female, presents to a primary care practice where she has been a patient since 5 years of age. She is accompanied by her maternal aunt. Michelle is usually accom-panied by her mother. She is up to date with her immunizations including HPV series. Her last visit was 10 months ago for strep pharyngitis. She was very quiet and less interactive at that visit but when asked if anything was bothering her said “just my throat. ” Michelle tells you she is here today because she identifies “more as a boy,” saying “I've felt this way for about 2 years but was afraid to tell anybody before. I'm not afraid now and have told my mother and my aunt. I'm tired of lying by not saying anything and want to do things differently. My mom said I should come and talk to you because we like and trust you. ” Michelle's aunt ver-ifies this, saying, “My sister is still a little freaked out about this but wants what is best for Michelle. That's why she asked me to come with her today. ” Michelle's mom would also like her to have a physical check‐up, since she hasn't been seen for almost a year. Michelle's aunt leaves the exam room to allow her privacy. Past medical/surgical history: Michelle has a positive medical history for strep pharyngitis, which resolved with antibiotics. She has no chronic illnesses, surgery, or hospitalizations. Menstrual history: She began menarche at age 11 with a regular 28‐day cycle and moderate bleeding. She expresses a desire to “not have my period. ” Family history: Maternal family history is positive for grandmother with COPD, grandfather with hypertension. Mother and 9‐year‐old sister have no health issues. Paternal history is unknown. Father has problems with substance abuse. Social history: Michelle lives with her mother and younger sister in a rural, farming area. Her father is known but has little contact with the family. Michelle is a sophomore at the public high school. Her mother works full‐time at a local manufacturing plant. Michelle has a close relation-ship with her mother and maternal aunt. She denies alcohol and tobacco use, does admit to “smoking weed once but I hated it. ” She denies depression but admits previous anxiety about her lifestyle choice. She reports her anxiety is “pretty much gone” since she has “come out” to her mother and aunt. She admits being attracted to other girls but denies any sexual experiences. She Case 5. 7 Sexual Identity By Betsy Gaffney, MSN, APRN, FNP‐BC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
128 The Adolescent has recently told a few other students about identifying as a boy, noting “it's hard to be different in this area. ” Medications: No regular medications. Allergies: Seasonal (spring) allergies. NKDA. OBJECTIVE General: Alert, pleasant adolescent; well groomed with good hygiene. Cooperative with good eye contact. Vital signs: Height: 63. 5 inches; weight: 112 pounds; BMI 19. 5 (43rd percentile); B/P: 108/70; HR: 72; RR: 15. Cardiac: RRR; S1‐S2 normal; no murmur, rub, or gallop. Respiratory: Normal respiratory effort; lungs clear to auscultation bilaterally. Abdominal: Soft, nondistended, nontender, with positive bowel sounds x 4 quadrants. Breasts: Tanner stage IV. PHQ‐9: Negative. CRITICAL THINKING What concerns should be addressed at this visit? _____Sexual identity_____Anxiety/Depression_____Desire for amenorrhea What case‐specific questions should be asked addressing Michelle's desire for amenorrhea?Are any referrals needed?What complications exist related to the rural setting?Are there implications for future medical care?What psychosocial challenges present with “coming out”? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
129 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Peter is a 16‐year‐old male who presents to your pediatric primary care office with complaints of right knee pain and swelling for 1 week. He can bear weight on his leg with only mild dis-comfort. He lives in New York City, but reports that he spent the summer working as a camp counselor in Madison, Connecticut. He resides at the camp while working there and spends his days hiking and doing outdoor activities. He has also participated in summer soccer clinics but does not recall a specific injury, and has attributed his occasional muscle aches to his activity levels. Peter denies any current rashes, but does state that he had a lot of bug bites and poison ivy exposure during his time working as a camp counselor and has generally ignored the symp-toms. He describes a few weeks of feeling more tired with intermittent headaches, but believes it's due to spending time in the sun and working with kids. He isn't sure whether he has had a fever. He also denies any pain or swelling in other joints. He did not go see the nurse on‐site at the summer camp. He reports he is sleeping through the night and his appetite has been good with no recent weight loss. Past medical history: Patient is a healthy 16‐year‐old male with no significant past medical history. Family history: Maternal and paternal family history is unremarkable. Patient has 1 sibling, a sister, who is well. A maternal grandmother has rheumatoid arthritis, lupus, and hypertension. Social history: Peter lives at home with his parents and younger sister. He has a pet dog that sleeps in his room. He is attending high school and in the 11th grade and is also an avid soccer player. Medications: Daily multivitamin. Allergies: Amoxicillin (hives, at age 2)Case 5. 8 Knee Pain By Jessica Chan, MSN, APRN, PPCNP‐BC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
130 The Adolescent OBJECTIVE Vital signs: Weight: 140 lbs; height: 68 inches; BMI: 21. 3; temperature: 100. 4°F; HR: 76; RR: 16; B/P: 108/72. General: Alert, tired appearing but in no acute distress. HEENT: Head is normocephalic and atraumatic. Scleras are clear. PERRLA bilaterally. Normal fundi exam bilaterally. Otoscopic exam reveals normal tympanic membranes with visible land-marks and appropriate light reflex. Nares are patent. Oropharynx is normal without erythema or exudate. Tongue is midline. Skin: No rashes noted on exam. Skin is warm and dry. Neck: No lymphadenopathy present. Full range of motion with no reported pain. Respiratory: Lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi present. Cardiovascular: Regular rate and rhythm. S1S2 normal. Pulses 2+ throughout. Gastrointestinal: Abdomen soft, nontender, nondistended, with no masses or hepatosplenomeg-aly palpated. Bowel sounds normoactive in all 4 quadrants. Neurological: Alert and oriented. Grossly normal. Sensation intact to lower extremities. Patellar and Achilles deep tendon reflexes 2+ bilaterally. Musculoskeletal: Assessments of the joints, with a particular focus on those of his right lower extremity (hip and ankle) are normal with the exception of the right knee. Left lower extremity exam is normal, and there is obvious asymmetry between the two knees. To right lower extremity: minimal tenderness to the knee joint upon palpation. The knee feels warm to touch. Non‐pitting edema is present. Further exam displays a positive “bulge” sign, evidence of fluid collection in the joint, as well as a negative Mc Murray test and negative anterior drawer sign test/Lachman test. The patella tracks normally. Range of motion of the right knee is limited due to swelling, with full extension but flexion limited to only 90°. No hypermobility is noted. Full strength (5/5) is noted to right lower extremity, and Peter's gait is normal with no limp at time of exam. CRITICAL THINKING Which diagnostic tests should be ordered in this case and why?___Complete blood count (CBC)___Comprehensive metabolic panel (CMP)___Erythrocyte sedimentation rate (ESR)___C‐reactive protein (CRP)___Rheumatoid factor___Anti‐nuclear antibody (ANA)___Lactic acid dehydrogenase (LDH)___Enzyme‐linked immunosorbent assay with reflex Western blot (ELISA)___X‐ray___Magnetic resonance imaging (MRI)___Synovial fluid (cell counts, Gram stain, culture and sensitivity, PCR) | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Knee Pain 131 What is the most likely differential diagnosis and why? ___Infectious cause (septic arthritis, osteomyelitis, Lyme arthritis)___Autoimmune diseases (juvenile idiopathic arthritis, systemic lupus erythematous)___Trauma/Injury___Malignancy (tumor secondary to osteosarcoma, lymphoma, neuroblastoma) What is the plan of treatment?What are the plans for referral and follow‐up care?What health education should be provided to this patient?What demographic characteristics might affect this case?Are there any standardized guidelines that should be used to treat this case? If so, what are they? Is there any other information that would be helpful in determining a diagnosis?If this patient were 6 years old, would it change how he would be tested and treated?At what point would inpatient treatment be more appropriate than outpatient for this patient? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Section 6 Women's Health Case 6. 1 Preconception Planning 135 By Sara Smoller, RN, MSN, ANP-BC Case 6. 2 Bleeding in the First Trimester of Pregnancy 137 By Meredith Scannell, Ph D, MSN, MPH, CNM, CEN, SANE-A Case 6. 3 Night Sweats 139 By Ivy M. Alexander, Ph D, APRN, ANP-BC, F AANP, FAAN and Annette Jakubisin-Konicki, Ph D, APRN, FNP-BC, ANP-BC, FAANP Case 6. 4 Pelvic Pain 145 By Meredith Scannell, Ph D, MSN, MPH, CNM, CEN, SANE-A Case 6. 5 Vaginal Itching 147 By Sara Smoller, RN, MSN, ANP-BC Case 6. 6 Redness and Swelling in the Breast 149 By Karen M. Flaherty, MSN, MEd, APRN-BC, CBCN Case 6. 7 Sexual Assault 151 By Meredith Scannell, Ph D, MSN, MPH, CNM, CEN, SANE-A Case 6. 8 Abdominal Pain 155 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 6. 9 Urinary Frequency 157 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 6. 10 Headache 159 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 6. 11 Fatigue and Joint Pain 161 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
134 Women' s Health Case 6. 12 Muscle Tenderness 165 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 6. 13 Insomnia 169 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
135 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Delilah is a 28‐year‐old female who presents to discuss her plans to conceive. She is in a monog-amous relationship with her husband. They are excited about the possibility of starting a family and want to do so in 6 months when her husband gets out of law school. Delilah wants to know what she should be doing to ensure that she is healthy and has a healthy pregnancy. She is worried she may have difficulty getting pregnant as her older sister had to go through in‐vitro fertilization; she is wondering if she needs a referral to a fertility specialist. She has never been pregnant before. Her last Pap smear was 3 years ago and was normal. Her last menstrual period was 2 weeks ago. She reports regular menses. Past medical history: G0P0; moderate persistent asthma, currently well controlled; appendectomy at age 21 Family history: Mother with Type 2 diabetes; father with bipolar depression (poorly managed)— she has minimal contact. Social History: Delilah works as a flight attendant 7 days on, 7 days off. She engages in minimal physical activity other than being active/on her feet at work. She's been married for 2. 5 years and feels safe at home. Her husband is in law school. Delilah drinks 1-2 glasses of wine per night and smokes “socially” about 5 cigarettes per week. She denies any marijuana or other drug use. Her sleeping habits are poor; when she is working she is flying between time zones and often is awake overnight. She states she averages about 5 hours of sleep per night. She drinks 3-4 cups of black coffee daily. Medications: Fluticasone inhaler 220mcg 1 puff bid; albuterol inhaler 1-2 puffs q6h prn shortness of breath; Apri OCPs; Ibuprofen 200-400 mg prn headache Allergies: NKDACase 6. 1 Preconception Planning By Sara Smoller, RN, MSN, ANP‐BC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
136 Women' s Health OBJECTIVE Vital signs: Temperature 97. 6°F (orally); BP 118/72; pulse 72 and regular. She is 5 ft 5 inches tall and 183 pounds. General: Delilah is pleasant and cooperative and is sitting comfortably in the exam room. Eyes: PERRL. No injection or icterus. Mouth: No lesions or exudates. Neck: Thyroid palpable without enlargement or nodules. Cardiac: Regular rate and rhythm, no murmurs. Lungs: Clear bilaterally. Breasts: No lumps, masses, nipple discharge, or skin changes. Abdomen: Soft, nontender, nondistended. No palpable masses or hepatosplenomegaly. CRITICAL THINKING What health recommendations should be made for Delilah in order to help her prepare for pregnancy? What laboratory/diagnostic testing is recommended?How Delilah's medication list be adjusted? Are any of the medications teratogenic? Are there any medications/vitamins or supplements she should start taking? When should she stop her birth control pills?How should she be counseled about seeing a fertility specialist? When would this be recommended? Would anything be different if Delilah were 38 instead of 28?Are any other referrals recommended? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
137 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Tasha is a 44‐year‐old female who presents with a sudden onset of heavy vaginal bleeding. She reports that the bleeding started 2 days ago; it started slowly but progressed to heavy bleeding that required menstrual pads to be changed every 2-3 hours since awaking this morning. Tasha also reports significant cramping and pain in the lower abdomen. She describes having irregular menstrual cycles over the past year due to perimenopausal changes. Her last menstrual cycle was 2 months ago; it was light and lasted only 3-4 days. Tasha reports some occasional nausea over the past few weeks that occurs for short durations in the morning. Past medical history: History of retinal detachments requiring surgical repair. Menstrual history: Tasha began her menstrual cycle at the age of 14. Prior to beginning perimeno-pause, she had 28‐day cycles lasting 5-6 days. Obstetrical history: G4 T2 P0 A2 L3. Tasha had 2 full‐term pregnancies. The first was a singleton at 38 weeks' gestation in which the delivery was an uncomplicated normal spontaneous vaginal birth. The second was a twin pregnancy at 37 weeks via uncomplicated Cesarean section. Tasha has also had 2 spontaneous miscarriages. Family history: Tasha's mother has a history of tension headaches and transient ischemia attacks. Her father has a history of hypertension and myocardial infarction. Her sister has a history of systemic lupus erythematosus and infertility issues. Social history: Tasha does not smoke; she drinks 4-5 times each week with 1-2 glasses of wine per setting. She reports occasionally drinking more than 6 drinks in a setting 1-2 times per year when there are celebratory occasions such as weddings. She is married and works as a funeral director. She has 1 teenage daughter who is in her senior year in college and two 19‐year old sons who started college in the fall. She has been married for 20 years to her high school sweetheart. She denies any concerns of domestic violence and reports feeling safe at home. Sexual history: Tasha reports being in a mutually monogamous relationship with her husband. She engages in sexual activity 1-2 times per week and reports feeling satisfied with the level of sexual activity. She denies any use of condoms; she is not concerned about pregnancy because she is perimenopausal. Case 6. 2 Bleeding in the First Trimester of Pregnancy By Meredith Scannell, Ph D, MSN, MPH, CNM, CEN, SANE‐A | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
138 Women' s Health Genitourinary: Tasha denies any dysuria, frequency, or incontinence. Medications: Tasha take no prescribed medication; over‐the‐counter medications include multi-vitamin QD, Vitamin D 200IU QD, fish oil 1,200 mg QD, ibuprofen 600 mg, as needed for pain. Allergies: Shellfish (rash), IV contrast (rash), Reglan (difficulty breathing). OBJECTIVE General: Tasha appears in some distress and is guarding of her lower abdomen. She is neatly dressed; affect is appropriate for the situation. Vital signs: BP: 110/52 (L) sitting; P: 90; RR: 18; temperature: 97. 8°F; weight: 185 lbs; height: 5 ft 5 inches. HEENT: Head: Nontender, without masses, hair with normal distribution. Eyes: Clear conjunc-tivae; PERRLA and intact. Ears: Clear external auditory canals, hearing normal. Mouth/throat: Light pink mucosa, dentition normal. Skin: Pink, warm, no rashes, and no lesions. Abdomen: Soft, nondistended, +tenderness lower abdomen above symphysis pubis, no rebound, no Turner sign, no Cullen sign. Pelvic: Inguinal lymph nodes without swelling or tenderness; no adnexal masses, vaginal mucosa moist light pink. Uterus midline and globular. Cervical os dilated, with blood, no tissue observed. No cervical motion tenderness. Blood noted in the vaginal vault, no tissue noted. CRITIAL THINKING What is the most likely differential diagnosis in this case?___Spontaneous inevitable abortion___Ectopic pregnancy___Cervicitis Which diagnostic tests are required in this case and why? ___CBC with differential___Blood type with Rhesus type and antibody screen___Beta h CG___Progesterone level___Doppler fetal heart tones___Transvaginal ultrasound___Abdominal ultrasound What are the concerns at this point?What is the plan of treatment?What are the plans for follow‐up care?Are there any standardized guidelines that should be used to treat this case? If so, what are they? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
139 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Susan is a 50‐year‐old Black female who presents for her annual physical with a complaint of hot flashes and night sweats. Susan reports that some of the night sweats are drenching. She is having difficulty sleeping and is finding it hard to function at work. Susan says her symptoms have been present for about 4-8 months. They seem to be increasing in intensity and frequency. She says, “some days I think I am going crazy! I cannot sleep and I am so easily frustrated and tired all of the time. ” She expresses embarrassment about sweating at work and says that she sometimes has trouble remembering things and staying focused at work meetings. Past medical history: No major chronic medical problems, + high blood pressure at the end of her second pregnancy (resolved with the birth), + seasonal allergies. Surgical history: Tonsillectomy at age 6. Wisdom teeth excisions at age 20. Family history: Mother: osteoporosis, mild depression; father: cardiovascular disease (CVD), hypertension, possibly diabetes mellitus; sister (3 years older): “terrible menopause symptoms,” recently diagnosed with a thyroid problem; brother (2 years younger): hypertension; MGM: oste-oporosis, depression; PGF: early CVD with myocardial infarction at age 50. Social history: Susan lives with her husband of 19 years, their two daughters, and the family dog in a private home that they own. She is employed as an editor with a private press agency and enjoys her work. She reports feeling stressed at work lately due to difficulty remembering tasks and missing deadlines as a result. She reports that the most important recent life event was her daughter's graduation from high school. She is happy for her daughter as she was admitted to the university of her choice, but Susan is not looking forward to having her leave home in the fall. She describes her usual day as follows: awakes around 6 a. m., makes breakfast for herself and the family, showers and dresses for work, drives to work, and is at her desk by 8:30 a. m. She leaves work around 5:30 p. m. and drives home. She makes dinner most evenings and spends time in the evening assisting her younger daughter with homework and doing household chores. She starts getting ready for bed around 10 p. m. She reports walking the dog each day for about 1. 5 miles, usually in the evening unless it is too hot. Case 6. 3 Night Sweats By Ivy M. Alexander, Ph D, APRN, ANP‐BC, FAANP, FAAN and Annette Jakubisin‐Konicki, Ph D, ANP‐BC, FNP‐BC, FAANP | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
140 Women' s Health Diet: Her 24‐hour diet recall reveals a bagel with cream cheese and coffee (black) for breakfast, salad with cottage cheese for lunch, grilled fish with potatoes and salad for dinner, and no snacks. She reports that she eats out about once per week and enjoys dessert on occasion. Substance use: Susan denies use of tobacco. She reports alcohol use as 1 glass of red wine most evenings. She denies use of recreational/illicit drugs. Safety: She reports feeling safe at home with her husband and family. She had 1 partner long ago who threatened her physically, but she has had no contact with him for many years. Since then she has never been hit, slapped, kicked, or otherwise physically hurt by anyone. She denies ever being forced to have sexual activities when she did not want to. She uses a seatbelt and sunblock regularly and has working smoke detectors and carbon monoxide detectors at home. Her husband does have a hunting rifle, which is kept locked with the ammunition stored separately. She denies any concerns for her children or personal safety with regard to the rifle. She denies having any current concerns about HIV. Medications: OTC antihistamines for allergies PRN; MVI daily; calcium (when she remembers); nasal spray for allergies PRN. Allergies: NKDA, NKFA, +seasonal allergies. General: Susan describes her overall health as “good, but getting weird lately. ” She reports a recent weight increase of about 4 lbs. She identifies her usual weight as 145 lbs. She reports fatigue and reduced energy since her hot flashes and poor sleep began. She denies any substantive premenstrual syndrome (PMS) symptoms. “I sometimes crave salty foods or chocolate, but it is not anything big. ” She denies symptoms of premenstrual dysphoric disorder (PMDD). Mood: Susan reports her usual mood as “generally good, but I feel crabby when I don't sleep well. ” Recently she notes increased moodiness, especially after a night of poor sleep. She denies feeling nervous or anxious, but admits to feeling irritable and getting angry more easily than usual when she is tired and having more hot flashes. She says, “I feel depressed. I don't sleep well, and most of the things I used to enjoy doing irritate me now. I feel like I am going crazy. ” She denies anhedonia and with questioning says that she enjoys reading, eating out with her husband or friends, shopping with her daughters, and doing yoga classes. Susan denies eating disorders; she says, “sometimes I eat when I feel irritated, you know, comfort food like chips or chocolate; and it doesn't even make me feel better! But no, I don't think I have an eating disorder. ” Cognitive: Susan describes difficulty with concentration and memory, especially at work after a night of particularly poor sleep or several nights of interrupted sleep. She denies problems with cognition, noting that she thinks clearly and can follow the conversation. Her issue is “with remembering what I said I would do. If I don't write it down, it is likely that it will not get done. ” She does use lists for shopping, puts appointments in a calendar, and carries a notebook to write down tasks when at work. Systemic: Susan reports that she began having hot flashes about 8 months ago. They have been slowly and progressively getting worse. She does have night sweats as well; sometimes she has to change her pajamas and sheets. She describes the severity of the hot flashes as 4-10 on a 1-10 scale: “sometimes they are tolerable and I just feel hot; other times I am completely drenched with sweat. ” She reports having hot flashes during the day anywhere from 6 to 20 times. Her night sweats occur anywhere from 2 to 10 times nightly. HEENT: Susan denies any problems with headaches, unless she forgets her morning coffee; and then, she says, “I get a headache around 2 p. m., but if I have a cup of coffee then it goes away. Of course then I don't sleep well. ” Susan reports minor changes in her vision over the past 3 years, requiring her to use reading glasses more and more often. She denies recent changes in hearing, | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Night Sweats 141 smell, taste, or swallowing. She reports some increased dry eye symptoms and finds that she needs to use eye lubricating drops, especially when she is doing a lot of work on the computer. She has seasonal allergies and experiences sneezing, rhinorrhea, and itchy eyes year round and especially in the early fall. Respiratory: Susan denies having any cough, wheeze, or shortness of breath in the recent past. Cardiovascular: Susan denies chest pain, palpitations, dyspnea on exertion, peripheral edema, or a history of blood clots. She says that she has always had cold hands and feet: “Maybe it is Raynaud's. They get so cold and take a long time to warm up. I am okay if I remember to wear gloves and keep my feet warm. ” Breast: Susan reports that she does do self‐breast exams, usually each month right after her period. She has forgotten often this past year since she has been missing periods. She denies any concerns or recent breast changes. She denies any discharge, pain, or tingling. She breastfed each of her daughters. Gastrointestinal: Susan reports occasional heartburn after a large or spicy meal that is relieved with Maalox. She denies persistent abdominal pain and reports daily regular bowel movements without constipation or recent changes in color, consistency, or pattern of stools. Specifically, she denies seeing any blood or experiencing fecal incontinence. Genitourinary: Susan reports some urgency and occasional leakage of small amounts of urine, especially with coughing or laughing. She denies urinary frequency; history of recurrent urinary tract infections, pyelonephritis, or renal stones; and urine dribbling or outright incontinence. She says she does not have dysuria. She reports occasional nocturia of once or twice at night, but is unsure if this wakes her or if she is awake and then feels she needs to urinate before going back to sleep. Gynecological: Susan reports no abnormal Pap smears or gynecological surgeries. She denies vaginal or vulvar discharge, itching, irritation, soreness, burning, abnormal bleeding, or lesions. She denies pelvic pain or rash. She reports some vaginal dryness, especially noticed with sexual activity. Pregnancy history: Susan has been pregnant twice. She is P2, G2 with two healthy living daugh-ters aged 15 and 18 years. She reports that she breastfed each daughter, the older one for 6 months and the younger one for 8 months. Menstrual history: Susan reports that her last menstrual period was 6 weeks ago. She reports that the menses was typical and lasted for 6 days with 1-2 days of light flow, followed by 3 days of heavier flow, and then 1-2 days of light spotting. She experienced menarche at 13 years of age and after the first few years had pretty regular periods occurring every 28-30 days. Over the past year she has had some missed periods and some with flow that was lighter than her usual pattern. She had one period with light flow that continued for about 2 weeks. Contraception: Susan reports that she used oral contraceptive pills for contraception in the past. She has not taken any type of hormone for contraception for the past 10 years because her husband had a vasectomy when they decided not to have any more children. Sexual: Susan reports that she is sexually active with her husband. She is mostly satisfied but notes that it has become harder to get adequately lubricated and that it takes longer to achieve orgasm. She reports she has had 6 lifetime partners and has been monogamous with her husband for over 20 years. She reports that her desire/libido is satisfactory but is less strong than it was 1 year ago. She says that this is “a bummer. We have always had a good sex life and I miss wanting it like I used to. ” Her arousal is reported as satisfactory, but “it takes longer to get ready than it used to. ” She usually does achieve orgasm but “it takes longer than it used to and sometimes he is already | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
142 Women' s Health finished and I am left feeling a bit frustrated. ” She denies dyspareunia. She reports their usual sexual practices include cuddling and kissing, then foreplay that includes genital manipulation, and then vaginal intercourse with penile penetration. They have used OTC lubricants recently, due to her dryness. She says she feels good and enjoys sex when it happens, but she doesn't ini-tiate activity or wish for it like she used to. She reports their relationship quality as, “Oh, really good. When he finishes before me we laugh about it and talk it over. Sometimes he brings me to orgasm manually, but it can take a long time. ” Musculoskeletal: Susan reports that she has noticed some vague joint and muscle pain over the past year. It seems better when she gets regular exercise and does not stop her from her usual activities. Endocrine: Susan denies polydipsia, polyuria, polyphagia, and symptoms of diabetes mellitus type 2. Skin/Hair: Susan denies noticing any recent skin changes or lesions of concern. She has noticed some increased acne around her mouth, skin dryness and wrinkles, and dry/thinning hair, espe-cially on her head. She denies hirsutism or facial hair. Hematologic: Susan denies any bleeding or bruising that doesn't correlate to a specific injury. Neurologic: Susan reports some numbness and tingling if her hands or feet get too cold, but not otherwise. She denies fainting, dizziness (vertigo), feeling off balance, or having difficulty walking. Sleep: Susan's usual bedtime routine includes nighttime washing and tooth brushing followed by reading or watching TV for about 30 minutes. She denies use of stimulants except for coffee each morning. She does wake every night with hot flashes/sweats. She is able to fall back to sleep but reports that it can take up to an hour depending on whether she needs to change her pajamas or sheets and how long it takes to feel cool again. She usually goes to bed around 10 p. m. and falls asleep around 10:30 p. m. She gets up for work around 6 a. m. most days. She reports that she usually does not feel refreshed when she wakes up. OBJECTIVE Vital signs: BP: 132/80 (L) sitting; P: 78; RR: 10; weight: 152 lbs; height: 5 ft 7 inches; BMI: 23. 8. General: Appears well; in no apparent distress; neatly dressed; appropriate affect. HEENT: Head: Nontender; without masses; hair thinning slightly in some areas. Eyes: Clear con-junctivae; PERRLA intact; EOMI; fundi sharp optic discs; normal retinal arterioles; no A‐V nicking. Ears: Clear external auditory canals; TMs + light reflex and landmarks visible; hearing grossly normal. Mouth/Throat: + normal mucosa, tongue, pharynx, and tonsils; dentition in good repair. Neck: Supple, without lymphadenopathy. Thyroid nontender, without palpable masses or enlarge-ment. Carotids without bruits. Respiratory: Clear to auscultation and percussion, anterior and posterior; without wheezes, rales, or rhonchi. Cardiac: RRR: normal S1 and S2 without murmurs, rubs, or gallops. Breasts: Without masses, skin changes, or discharge bilaterally; no lymphadenopathy. Abdomen: Soft, nondistended, nontender; + bowel sounds × 4 quadrants; without HSM, masses, or bruits. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Night Sweats 143 Gynecological: Vaginal mucosa slightly dry, rugae present; uterus firm and anteverted, nontender, without palpable masses; adnexa nontender, without palpable masses bilaterally; no lesions noted. Rectal: No lesions or masses noted; + external hemorrhoids; nontender; + normal sphincter tone. Extremities: Without cyanosis, edema, or clubbing; +2 pulses bilaterally. + full range of motion throughout, nontender joints without crepitus. Neurologic: CN II-XII grossly negative; 5/5 motor strength, gait even; DTRs 2+; Romberg negative. CRITICAL THINKING What are the top three differential diagnoses to consider for Susan and why? Which diagnostic tests are required for managing Susan's condition and why?What are the concerns at this point?What is the plan of treatment options to be discussed with Susan?What are the recommendations for referral and follow‐up care?What health education should be provided for Susan?What if Susan also had diabetes or hypertension?What if Susan were over age 65?Does Susan's psychosocial history affect the management recommendations?Are there any standardized guidelines that should be used when developing a management plan for Susan? If so, what are they? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
145 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Shanae is a 32‐year‐old female who presents with lower abdominal pain and fever. Fevers at home range between 99. 4°F to a maximum of 101. 7°F. She describes the lower abdominal pain as a constant dull ache, nonradiating, with a pain scale ranging from 5/10 to 8/10. The pain is worse with sexual intercourse. Shanae is taking acetaminophen 650 mg every 4 hours with minimal relief. She reports general malaise and that for the past 2 weeks she has been having heavy, purulent vaginal discharge. Three weeks ago, Shanae went to an urgent care clinic for dysuria. At that time, there was concern about a sexual transmitted infection and Shanae was treated for gonorrhea and chlamydia. Past medical history: Polycystic ovarian syndrome, gonorrhea, herpes simplex virus type‐2Gynecologic history: Two abnormal Pap smears requiring repeat testing and cone biopsy with negative results. Menstrual history: Menstrual cycles irregular between 28 and 35 days, lasting 5-7 days of heavy bleeding. LMP 1 week ago. Family history: Mother with history of cervical cancer and died at the age of 38, father with alcohol and substance abuse, no other history known. Sexual history: Shanae reports having a poor sexual relationship with her husband, from whom she is separated. She left her husband after finding out he was having extramarital relationships and has engaged in several sexual relationships of her own. She now reports current sexual activity as intercourse with only one partner. She and her partner use condoms on most occasions; however, there has been a few occasions when they did not use condoms. She is currently satisfied with her sexual partner with whom she engages in vaginal, oral, and rectal sexual intercourse. Substance use: Shanae denies use of tobacco. She reports occasional alcohol use of 1-2 drinks per month. She reports daily or near daily smoking of marijuana and has used cocaine in the distant past, none recently. Case 6. 4 Pelvic Pain By Meredith Scannell, Ph D, MSN, MPH, CNM, CEN, SANE‐A | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
146 Women' s Health Safety: Shanae reports feeling safe at home and in her current relationship. She says that the rela-tionship with her husband was beginning to feel unsafe due to constant fighting. Since the sepa-ration, she has had no safety concerns and in the process of finalizing a divorce. Medications: Ibuprofen 600 mg as needed, OCP (Yasmin) once daily. Allergies: NKDA, OBJECTIVE General: Shanae is pleasant but appears in distress, guarding her abdomen. Vital signs: Temperature: 100. 4°F; BP: 100/52; HR: 110; respirations: 24. Skin: Hot to touch, no lesions, no rashes. Abdomen: Abdomen + bowel sounds, soft, nondistended. Positive suprapubic pain elicited upon palpation. No rebound tenderness, Turner sign, or Cullen sign. Pelvic: Cervix midline, friable cervical OS; yellow discharge noted from the OS. Positive cervical motion tenderness. No lymphadenopathy and no adnexal masses. Rectal: No lesions, no masses; normal sphincter tone. CRITICAL THINKING What is the most likely differential diagnosis in this case? ___Ectopic pregnancy___Pyelonephritis___Pelvic inflammatory disease Which diagnostic tests are required in this case and why? ___CBC___Nucleic acid amplification tests (NAAT)___Beta h CG___HIV___Wet mount___Treponema pallidum___Transvaginal ultrasound What is the plan of treatment?What are the plans for follow‐up care?What health education should be provided to this patient?Are there any standardized guidelines that should be used to treat this case? If so, what are they? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
147 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Martha is a 24‐year‐old female who reports vaginal itching for 3 days. She says that she can barely focus on other things because of the itching. She also reports a copious, white vaginal discharge. Her last Pap smear was at age 22 and was negative. She has not received the HPV vaccine series. Martha denies previous episodes and states that she is otherwise healthy. She denies fever, chills, nausea, vomiting, or diarrhea. She is sexually active with both male and female partners since the age of 15. She states that recently she has been exclusively with females but has had 2 sexual partners in the past year. She states that she still feels somewhat confused about her sexual preferences. She admits to dyspareunia and burning with urination. She denies use of vaginal sprays, douches, or powders or the use of new soaps, detergent, or clothing. Her last menstrual period (LMP) was 3 weeks ago. Past medical history: Recurrent strep pharyngitis—last episode 3 weeks ago. Family history: Remarkable for diabetes mellitus and COPD. Social history: Martha is a college graduate and still lives with her widowed mother. She feels safe and has a good relationship with her mother but has not disclosed her sexual preferences to her mother. Martha does worry about their financial status as she and her mother have low‐paying jobs and do not have other financial support. They are currently renting their apartment from a friend. Martha does not smoke and denies substance use. Medications: None currently. She completed a 10‐day course of amoxicillin 1 week ago for strep pharyngitis. Allergies: Seasonal in spring. OBJECTIVE Vital signs: Martha is afebrile. Her BP is 110/70. Pulse is 64 and regular. Respirations are 12 and unlabored. She is 5 ft 3 inches tall and weighs 120 lbs. General: Martha is pleasant and cooperative but seems anxious about the visit. Case 6. 5 Vaginal Itching By Sara Smoller, RN, MSN, ANP‐BC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
148 Women' s Health Throat: No swelling or exudates. Cardiac: Regular rate and rhythm. Respiratory: Lungs are clear bilaterally. Abdomen: Soft, nontender, nondistended, and without organomegaly. Pelvic exam: Inguinal lymph nodes are without swelling or tenderness; vaginal mucosa is moist, pink, and mildly swollen. There is no foul odor; but there is a white, cottage cheese-like discharge at the introitus. The cervix is pink and without friability. There is no cervical motion tenderness (CMT). The p H of the vaginal discharge is within normal range (3. 8-4. 2). CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Pap smear___Cultures for gonorrhea and chlamydia___Urine testing for gonorrhea and chlamydia___Wet mount, including KOH and whiff test___Urinalysis If a wet mount were performed, what findings would be expected for the following diagnoses? Bacterial vaginosis Candidiasis Trichomonas What is the most likely dif ferential diagnosis and why? ___Bacterial vaginosis___Candidiasis___Trichomonas___Gonorrhea___Chlamydia___Herpes simplex___Urinary tract infection What is the plan of treatment?What education should be provided to Martha at this visit?Are any referrals needed?Is the family history of diabetes relevant to this case?How can the clinician support the patient regarding her confusion with her sexual preferences? NOTE: The author would like to thank Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN for her contribution to this case in the first edition of this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
149 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Jill is a 26‐year‐old female who presents today for evaluation of redness, swelling, and pain in her right breast. Three months ago she underwent bilateral nipple piercings while on vacation in the Caribbean. Both sites had healed well until 4 days ago, when she noted “mild” redness on her right lower breast. This has increased in size and depth of color and she began experiencing swell-ing and pain in the right breast. Last night she noted a small amount of drainage on the right side of bra and felt mildly feverish. Past medical history: Jill is an otherwise healthy 26‐year‐old female of Ashkenazi Jewish heritage who had the usual childhood illnesses. Her immunizations are up to date. She's had no chronic illnesses and has no past surgical history. Family medical history: Jill's mother and father (Ashkenazi Jewish) are alive and well. She has 2 brothers, ages 20 and 18, with no significant medical problems. Her paternal grandmother is age 67 and has Type 2 diabetes mellitus; she was treated for left breast cancer at age 43 and tested positive for the BRCA 1 and 2 gene. Jill's paternal grandfather is age 70 and is alive and well. Her maternal grandmother is age 65 and has high blood pressure; her maternal grandfather is age 67 and alive and well. Social history: Jill graduated with a degree in art and works as an assistant in an art gallery; she is applying to graduate school. Jill lives in Boston with a female roommate. Her alcohol intake includes 2-3 glasses of wine on the weekend. She has been smoking 3-4 cigarettes per day since age 20. She performs Pilates 2-3 times per week. Medication: Daily BCP, MVI, Tylenol if needed for headache. Allergies: Seasonal sllergies (spring), penicillin (rash and hives). Case 6. 6 Redness and Swelling in the Breast By Karen M. Flaherty, MSN, MEd, APRN‐BC, CBCN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
150 Women' s Health OBJECTIVE General: Pleasant young woman, who appears mildly unwell, in moderate discomfort; rates pain 4/10 located in R breast. Vital signs: Temperature: 100. 4°F; P: 90; BP: 100/60. Cardiac: Rate 96 and regular, no murmurs heard on auscultation. Respiratory: Rate 16 breaths per minute, lungs clear to auscultation in all lobes. Skin: Face is flushed. Right breast has marked redness and warmth over the lower half, left breast no redness or increase in temperature. Breast: Right breast is slightly swollen, with erythema extending over the lower half of the right breast, central area of induration within the area of erythema. Mild skin thickening and edema noted. There is a ring piercing through the right nipple, no drainage seen. Right breast has a tender area of induration within the central portion of the erythema. No other discrete or dominant masses found. No observable drainage seen from right breast. Left breast has a ring piercing through the left nipple, no swelling, erythema, or induration, also with piercing through the left nipple. Left breast is smooth to palpation with no discrete or dominant masses noted, no painful areas on palpation. Lymph: Left axillary nodes nonpalpable, nontender. Right axilla has 2 mobile, nontender, 0. 5 cm, oval palpable nodes. CRITICAL THINKING Which diagnostic tests should be considered? Which differential diagnoses should be considered?What is the most likely differential diagnosis and why?What is the plan of treatment?What is the plan for follow‐up?Would the workup or treatment be different if this patient were a man?Are any referrals needed?What health education is important for this patient? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
151 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Aiyata is a 22‐year‐old female who presents requesting treatment for sexually transmitted infec-tion. She reports she recently graduated from college and was out celebrating the graduation with some friends last night. She reports going to a bar where she met with a male friend who bought her drinks. She has a vague recollection of the night but awoke today naked in the bed with the male friend. She has a vague memory of having sex with the male friend but does not recall many of the details; she is not sure if a condom was used. She is concerned because she has been having vaginal spotting since the event and some pain and discomfort in the vagina. Past medical history: Depression, childhood sexual abuse, post‐traumatic stress disorder. Past surgical history: None. Menstrual history: LMP 2 weeks ago; she reports a 28‐day cycle and no menstrual irregularities. Genitourinary: Reports some dysuria that started this morning. Family history: Aiyata's mother has a history of alcohol abuse and hypertension. Her father's history is unknown. Social history: Aiyata was raised in a single‐parent home with her mother as the primary care-giver. She is currently living in an apartment with college friends. Aiyata recently graduated from college and works part‐time as a server. She reports being single since a breakup with her boy-friend. She had been in a mutually monogamous relationship with the boyfriend, but since the breakup, she has had 3 casual sexual partners. She practices safe sex with the use of condoms. Substance use: She occasionally consumes alcohol 1-2 times a week with 1-2 drinks per setting. She admits to occasional marijuana consumption, but uses no other recreational drugs. Medications: Oral contraception, Citalopram 20 mg daily. Allergies: No known drug allergies. Case 6. 7 Sexual Assault By Meredith Scannell, Ph D, MSN, MPH, CNM, CEN, SANE‐A | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
152 Women' s Health OBJECTIVE General: Ayita is sad appearing, talking softly, answering questions appropriately. Vital signs: Temperature: 98. 6°F; BP: 120/74; HR: 99; RR: 18. Skin: Abrasion on left knee and left elbow. Neurologic: Alert and oriented × 3HEENT:Head: Nontender, without masses, hair normally distributed. Neck: Lateral neck tender to palpation; dark red ecchymosed areas on right side of neck, trachea midline, no lymphadenopathy. Thyroid nontender, without palpable masses or enlargement. Eyes: PERRLA and EOMs are intact, left eye small subconjunctival hemorrhage. Oropharynx: Uvula is midline, no edema, redness, or ecchymosis. Respiratory: Lung sounds are clear to auscultate. Cardiac: Regular rate and rhythm. Breast: Tanner IV, symmetrical. Abdomen: Soft, nontender, nondistended; active bowel sounds. Pelvic:Vulva: No lesions or ecchymosis. The labia minora are red and swollen, tender to palpation; there is a small laceration at the posterior fourchette. Vagina: No active bleeding, very tender with speculum insertion, white discharge in vaginal vault. Cervix: Bright red and friable; positive cervical motion tenderness. Rectal: Rugae normal appearance, no lesions. CRITICAL THINKING What is the most likely differential diagnosis in this case and why? ___Sexual assault___Strangulation___Pelvic inflammatory disease Which diagnostic tests are required in this case and why? ___CBC with differential___Metabolic panel___LFTs___Toxicology panel___HCG___HIV___Urinalysis___NAAT___CT scan neck | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Sexual Assault 153 ___Transvaginal ultrasound ___Abdominal ultrasound What are the concerns at this point?What is the plan of treatment?What are the plans for referral and follow‐up care?What health education should be provided to this patient?Are there any standardized guidelines that should be used to assess or treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
155 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Rachel is a 17‐year‐old Caucasian female who presents with complaints of decreased appetite, fatigue, nausea, and intermittent abdominal pain for the past 2-3 weeks. She describes the abdom-inal pain as sharp and focused in the right epigastric area. She also reports some new‐onset pain in her right shoulder but attributes this to carrying around her baby more than usual. She denies vomiting, diarrhea, or constipation. Her typical diet consists of pizza, hot dogs, and salads. Rachel denies any association of her symptoms with food or hunger. Her last normal menstrual period was 3 weeks ago, and she has had 2 negative pregnancy tests at home. Past medical history: She delivered her son 6 months ago vaginally without complications. Her only other medical history includes a kidney infection 4 months ago. Social history: She smokes 7 cigarettes a day but admits, “I really don't need them. I am bored. ” Rachel lives with her boyfriend (the father of her child) and his parents. She moved in, far away from her home, only recently. Her parents made her leave their house when she told them she was pregnant, and they have no contact with her. She states that she feels safe at home and is enjoying her baby. Her boyfriend helps with the baby but often goes out at night with his friends and leaves her at home with the baby. She feels a little isolated because everyone works during the day and she has no access to transportation. She is dependent on her in‐laws if she needs to go anywhere by car, and they do not often support her need to go anywhere. Otherwise, she walks. She walked here today for her appointment. Medication: She is not allergic to any medication and only takes birth control pills. OBJECTIVE Vital signs: Rachel is afebrile. BP is 120/80. Pulse is 68 and regular. Eyes: PERRLA. EOMs are intact. Optic disks are sharp. Cardiac: Cardiac exam reveals regular rate and rhythm. Respiratory: Respirations are 12, steady, and unlabored. Lungs are clear. Case 6. 8 Abdominal Pain By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
156 Women' s Health Abdomen: Soft with mild tenderness to palpation (TTP) in the RUQ with a positive Murphy's sign. There is no CVA tenderness. Genitourinary: A urine dipstick reveals positive protein. A urine HCG is negative. Rachel is diagnosed at this first visit with possible cholecystitis and is given Antivert 12. 5 mg for her nausea. Blood is drawn and sent to the lab. Her urine is sent for analysis, and she is told to return in 1 week. Rachel returns 1 week later. Her bloodwork reveals a blood glucose of 45 mg/d L. Her other blood-work is within normal limits. Her urinalysis returns with few bacteria and no protein. Rachel reports that the abdominal pain has worsened and she now has headaches. She denies a history of migraines or frequent headaches. Her nausea is still present but decreased. Her exam remains unchanged. CRITICAL THINKING What is the most likely differential diagnosis in this case and why? __Cholelithiasis__Gastroenteritis__Diverticulitis__Insulin tumor__Gastric tumor__Cholecystitis Which diagnostic tests are required in this case and why? __Abdominal ultrasound__Abdominal CT scan__Head CT scan__KUB X‐ray__CBC__Metabolic panel__LFTs__Insulin level__C‐peptide__OGGT__Gastrin level What is the plan of treatment?Are any referrals needed?Does the patient's home situation influence the plan?Are there any standardized guidelines that should be used to treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
157 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Susan is a 42‐year‐old female who presents with a report of burning pain on urination for the past 2 days. She has been urinating frequently and finds that she has to run to make it to the bathroom in time to void in the toilet. She vaguely remembers similar symptoms once in college but doesn't remember what she was diagnosed with or how she was treated for it. She denies flank pain but does have some mild suprapubic pain. She admits to mild dyspareunia in the past few days. Susan is otherwise well but admits to being thirsty more frequently than usual. Her menses are regular, and her LNMP was 10 days ago. She denies vaginal itching, foul odor, or discharge. Her 2 children were born via vaginal deliveries without complications. She does not recall when she last had a pelvic exam or Pap smear and recalls a remote history of an abnormal Pap smear. She thinks she had a colposcopy at that time and after 1 year, she was told to resume a normal Pap smear schedule. Social history: Susan is a recently divorced mother of 2 young children. Her ex‐husband was “fooling around” while they were married, so Susan is worried that she might have a sexually transmitted infection. Since the divorce, Susan has had 1 new male sexual partner. They began their sexual relationship about 1 week ago and did not use condoms because Susan was on birth control pills and “I trust this new man. ” She works full‐time as a preschool teacher and takes care of her children, ages 12 and 15, by herself and without financial support from her ex‐husband. Susan does not smoke but has an occasional (1 per month) glass of wine. She admits to having used marijuana in college. Family medical history: Notable for diabetes Type 2 (mother) and hypertension (father). Medications: Birth control pills. OBJECTIVE General: The patient is in no acute distress and is pleasant and cooperative. Vital signs: Oral temperature is 98°F. BP is 116/74. HR is 64 and regular. Respiratory: Respirations are 14 and regular. Lungs are clear bilaterally. Case 6. 9 Urinary Frequency By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
158 Women' s Health Back: There is no CVAT. Cardiac: RRR S1/S2; without murmurs, clicks, gallops, or rubs. Abdomen: Soft, nontender, nondistended, without organomegaly. Bowel sounds are active in all 4 quadrants. Reproductive: Pelvic exam reveals no inguinal lymphadenopathy; moist pink vaginal mucosa, negative chandelier sign, and pink anterior cervix without friability. Cervical discharge is thin, white, and odorless. Samples are obtained for culture. This patient could also have provided a urine sample to test for gonorrhea and chlamydia. However, given her history with a new partner and an ex‐husband who had other partners, as well as the length of time since her last pelvic exam, it is reasonable to do a pelvic exam at this time. A Pap smear is also performed because Susan cannot recall when she last had one and there is none noted in the electronic record. The test will include HPV testing. The bimanual exam reveals no masses or tenderness. CRITICAL THINKING What is the most likely differential diagnosis and why?__Pregnancy__Acute cystitis__Interstitial cystitis__Diabetes mellitus__Pyelonephritis__Pelvic inflammatory disease__Urinary tract infection (UTI) Which diagnostic studies should be considered to assist with or confirm the diagnosis? __Urine dipstick__Urinalysis__Urine culture and sensitivity__CBC__CMP__TSH__Renal ultrasound__Abdominal and pelvic ultrasound What is the plan of treatment?What is the plan for referrals and follow‐up?Would the diagnosis change if the patient had fever and flank pain?Would the most likely diagnosis change if the patient were male?What is an important symptom to consider in an older adult?What if Susan were pregnant? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
159 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Sophia is a 35‐year‐old Latina woman who presents with a complaint of headaches that have been occurring more frequently over the past 2 weeks. She has never had any problems with headaches before. Rarely, she has had a headache after a stressful day but denies premenstrual headaches or frequent headaches until 2 weeks ago. Her headaches are left sided in the temporal area and are severe (7 out of 10 on a 1-10 scale) and throbbing. They occur 3-5 times each week. She occasion-ally becomes nauseous but rarely vomits. The headaches tend to last several hours and go away if she is able to get sleep. Sophia tries to retreat to a dark and quiet corner when the headaches begin. She sometimes sees “spots in front of her eyes” right before the onset of a headache. Otherwise, she has no trouble with her vision, has had no epistaxis, upper respiratory symptoms, or sinus symptoms. She denies trauma to her head or any neck stiffness. She denies fever, chills, numbness, or weakness. Past medical history: Sophia has been otherwise well and denies any previous surgeries or hos-pitalizations other than for 3 vaginal deliveries without complications. Family history: Migraine headaches in her mother and sister. Her uncle had a benign brain tumor that was successfully treated. Social history: The patient does not smoke, drinks 1 beer 3 times each week, and denies ever using recreational drugs. She is married and works as an administrative assistant in a busy office. She has 1 preteen and 2 teenagers at home, and their behavior sometimes causes her stress. Her husband is supportive and helpful. Medications: Sophia's medications include occasional ibuprofen for “aches and pains. ” She tried the ibuprofen for the headaches without relief. She takes no other medications. She states that her mother told her that she was allergic to penicillin as a child, but she doesn't know why. Case 6. 10 Headache By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
160 Women' s Health OBJECTIVE General: Sophia is well groomed. Her manner and speech are appropriate and she is articulate. She is in no apparent distress during the visit. Vital signs: The patient is afebrile. Her blood pressure is 140/90 (which she says is higher than her normal blood pressure). Pulse is 86, and respirations are regular at a rate of 12. HEENT: The eye exam reveals clear sclera, conjunctiva without injection, and PERRLA. EOMs are intact. There is no AV nicking or papilledema. Optic disks have clear margins. Nasal mucosa is without erythema or drainage. There is no sinus tenderness to palpation. Cranial nerves II-XII are grossly intact. Cardiac: Unremarkable. Respiratory: Unremarkable. Neurologic: The patient is alert and oriented. Thoughts are coherent and articulation is clear and appropriate. Sensation and proprioception are grossly intact, and the Romberg test is negative. Gait is steady. Brudzinski and Kernig signs are negative. CRITICAL THINKING What is the most likely differential diagnosis and why?___Migraine with aura___Migraine without aura___Cluster headache___Tension headache___Meningitis___Temporal arteritis___Psychogenic headache Are there tools that can be used to help assess this headache? If so, name two. Which diagnostic studies should be considered? ___CT scan___MRI___CBC___CMP___Lipid panel What is the plan of treatment?Are any referrals or follow‐up needed?Does the patient's psychosocial history impact how she might be treated?Is the patient's blood pressure the cause or the result of her headache?Would the treatment change if the patient were a smoker or on birth control pills? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
161 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Aliyah is a 22‐year‐old African American female who presents with profound fatigue, sore hands and wrists, and frequent episodes of oral and nasal ulcers. She has been told by others that she has a rash across her cheeks when she is exposed to the sun; and she has just begun to notice this herself. Aliyah describes the fatigue as debilitating, and she finds it difficult to work as a legal assistant. When she is home, she frequently naps; but this never fully relieves her fatigue. Her hands and wrists ache, and this further complicates her ability to do her job, as she is expected to type most of the day. She reports occasional cold sores since she was a teen, but recently these sores have become worse and harder to heal. She has also developed intermittent sores in the nose. Aliyah reports intermit-tent episodes of fever, and she has been using acetaminophen to control these episodes. She states, “I just don't have any energy, and I really don't feel well. ” Aliyah's menses have always been heavy and accompanied by significant dysmenorrhea. The periods started out regular (at age 12) but have gradually become less predictable. Aliyah is a smoker. She has been coughing but denies chest pain, palpitations, dyspnea, swelling of her extremities, seizures, headaches, changes in sensation, weakness, changes in bowel or bladder function, dry eyes or dry mouth, eye pain, or changes in vision. Past medical surgical history: None. Family history: No connective tissue or inflammatory diseases, heart disease, diabetes mellitus, or respiratory illness. Medications: Acetaminophen and a birth control pill. OBJECTIVE Vital signs: Temperature: 100. 6°F orally; HR: 68 and regular; RR: 12 and regular; BP: 110/64; weight: 110 lbs (down from 120 lbs 4 months ago); height: 5 ft 4 inches. Case 6. 11 Fatigue and Joint Pain By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
162 Women' s Health HEENT: Mild alopecia is noted. TMs are clear and intact. PERRLA; EOMs are intact; sclera and conjunctiva are clear. Aphthous ulcers are noted in the mouth and nose. Dentition is grossly intact. There is mild bilateral anterior cervical lymphadenopathy. Cardiac: RRR S1/S2; without murmurs, clicks, gallops, or rubs. Respiratory: CTA bilaterally. Skin: An erythematous rash is noted across the cheeks, sparing the nasolabial folds. Livedo is noted on the lower extremities. Nailfold capillaries are positive for loops. Musculoskeletal: No synovitis or swelling is noted. There is no TTP. There is LROM of wrists fingers bilaterally due to pain. Neurologic: Mentation is grossly intact. CNs II-XII are grossly intact. Sensation and propriocep-tion are grossly intact. DTRs are +2. Romberg is negative. Heel‐toe is negative. RAMs are negative. CRITICAL THINKING What is the most likely differential diagnosis and why?__Rheumatoid arthritis__Systemic lupus erythematosus__Vasculitis__Discoid lupus__Fibromyalgia__Osteoarthritis__Influenza Which diagnostic studies should be considered to assist with or confirm the diagnosis? __Urinalysis__Metabolic panel__CBC with differential__Lipids__TSH__CK__ESR or CRP__U1 ribonucleoprotein (RNP)__Rheumatoid factor__CCP__ANA with reflex__Anti‐DS DNA__Anti‐SM__Anti‐RO/SSA__Anti‐LA/SSB__Homocysteine__C3, C4__HIV__Hepatitis B__Hepatitis C__X‐rays (if so, what type?) | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Fatigue and Joint Pain 163 __Antiphospholipid antibodies (lupus anticoagulant [LA], Ig G and Ig M anticardiolipin [a CL] antibodies; and Ig G and Ig M anti‐beta2‐glycoprotein [GP] I) __Urine pr otein‐to‐creatinine ratio What is the plan of treatment? What is the plan for referrals and follow‐up?Are there other manifestations of this disease?Would it change the diagnosis or impact the prognosis or treatment if the patient were taking minocycline? What if the patient had a parvovirus? What are the potential complications of this disease? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
165 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Zelda is a 32‐year‐old female who reports tenderness when anyone or anything touches her. She has experienced these myalgias throughout her body for the past 6 months, and the pain is affecting her quality of life. She describes pain in the back of her head, her neck, her upper chest, upper back, her elbows, backside, and knees. The pain occurs on both sides of her body. “My joints feel swollen, and my skin burns. ” She feels profoundly fatigued and yet is unable to get a full night's sleep. She has trouble falling and staying asleep. She finds that she is often irritable, and this is affecting her relationships. She denies fever, chills, nausea, vomiting, and diarrhea. She denies changes in her hair, skin, or nails or any change in her menstrual period, which occurs every 28 days and lasts 5 days. Her LNMP was 3 weeks ago. She had unprotected sex 2 weeks ago with an old friend who consoled her after her move here. She denies any joint pain, dry eyes, dry mouth, ulcers, rashes, lesions, or morning stiffness. Past medical/Surgical history: Hypertension that is controlled; irritable bowel syndrome; and appendectomy age 14 years. Social history: She moved to this state 2 months ago and had been given opioids by her previous primary care provider. These helped moderately, and she would like some more. “At least they help me get some sleep. ” Zelda divorced her husband, prompting the move out of state; she moved here with her 2 teenagers, who are getting into trouble and are confused by the recent changes in their lives. Zelda admits to feeling sad often but denies suicidal ideation. She often feels unfocused and unable to concentrate. She denies use of tobacco, alcohol, and recreational drugs. Zelda grew up in a broken home. Her father was an alcoholic and was occasionally abusive to her. She has worked since age 15 and currently works in the school cafeteria so she can be around her children and be home when they come home. She receives some financial assistance from her ex‐husband. Family medical history: Mother had rheumatoid arthritis. Father died of colon cancer at age 65 years. Medications: Lisinopril 10 mg; Percocet 10/325 mg every 6 hours as needed for pain; MVI. The patient has been out of Percocet for 4 weeks. Case 6. 12 Muscle Tender ness By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
166 Women' s Health OBJECTIVE Height: 5 ft 3 inches; weight: 150 lbs; temperature: 98. 7°F oral. HR is 68 and regular. RR is 12 and regular. BP is 124/70. General: Teary, appears anxious. HEENT: Head: Normocephalic, mild tenderness to palpation (TTP) of occiput. Eyes: PERRLA, EOMs intact. Nose: No polyps, no erythema. Mouth and throat: No oral ulcers, no erythema, no exudates; tonsils are +2. Neck: TTP, LROM on rotation due to pain; thyroid is nonpalpable. Cardiac: S1/S2; RRR without murmurs, gallops, clicks, or rubs. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, no bruits; positive for bowel sounds; nontender; nondistended. No organomegaly. Neurologic: Mentation grossly intact; CNs II-XII grossly intact; DTRS +2 UEs and LEs; negative Romberg; negative RAMs; proprioception and sensation grossly intact. Musculoskeletal: There is FROM, and strength is 5/5 throughout. There is no synovitis, and there are no effusions. Skin: No rashes or lesions noted. CRITICAL THINKING What is the most likely differential diagnosis and why? __Rheumatoid arthritis __Systemic lupus erythematosus__Fibromyalgia__Sjögren's syndrome__Osteoarthritis__Thyroid disease__Pregnancy__Mononucleosis__Celiac serology__Vitamin D Which diagnostic studies should be considered to assist with or confirm the diagnosis? __TSH__CBC with differential__Metabolic panel__ESR and CRP__Rheumatoid factor__Anti‐CCP__ANA__SS‐A and SS‐B__X‐rays__MRIs | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Muscle Tenderness 167 __HCG __Urine dipstick__None What is the plan of treatment? What is the plan for referrals and follow‐up? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
169 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Iris, a 48‐year‐old Asian female, presents with a report of insomnia and impaired concentration. She has not slept through the night for approximately 6 weeks and finds that while she can fall asleep readily, she is too restless to stay asleep. At work (she works as an office manager), she is unable to concentrate and has found herself making simple mistakes. Iris is easily fatigued and states that she frequently feels warm and flushed, but she attributes this to “the time of life. ” Her menstrual periods have become irregular. Her LNMP was 2 months ago. It lasted 10 days and was slightly heavier than usual. Iris states that she occasionally feels her heart “fluttering” when she feels anxious. She is surprised at this because she has always felt that she coped well with life and was generally happy. “Now, the littlest things seem to bother me and I feel my heart start to flutter. Oh, the change of life. I have dreaded it. Can you give me something for it?” Iris denies fever, chills, pain, weakness, or tremors. Elimination: Iris has not noticed any changes in her weight or loose stools. Past medical history: Iris had a hospitalization for a Cesarean section without complications 15 years ago. She also had a hemorrhoidectomy 7 years ago without complications. Family medical history: Iris has a husband and 1 son who are alive and well. Her mother, age 67, has stage 1 Alzheimer's disease and hypothyroidism. Her father has diabetes mellitus Type 2 and a history of colon cancer. Both are alive. Social history: Iris lives with her husband and son and states that she is happily married and comfortable financially. She stopped using any form of birth control since her periods became irregular 6 months ago. She is a smoker, takes no medications, and has been generally healthy. OBJECTIVE The patient appears anxious but is pleasant and cooperative. Her weight is 136 lbs; she comments that this is 10 lbs less than the last time she checked her weight 3 months ago. Oral temperature is 100° F. BP is 148/94. HR is 96 and regular. Respirations are 12 and regular. 6. 13 Insomnia By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
170 Women' s Health HEENT: Hair is shiny and soft. No exophthalmos is observed. There is no lid lag or retraction. Sclerae are clear and conjunctivae are without injection. PERRLA and EOMs are intact. CNs II-XII are grossly intact. There is no cervical lymphadenopathy. Trachea is midline. The thyroid is mildly palpable with a bruit. There are no nodules. Skin: The patient's skin is warm and moist. Cardiac: HR: 96; RRR: S1/S2; no murmurs, clicks, gallops, or rubs. EKG reveals NSR without abnormalities. Pulmonary: Lungs are clear bilaterally. Abdomen: Soft without tenderness or distention. No organomegaly, no bruits. Bowel sounds are active throughout. Neurologic: There are no tremors. Sensation and proprioception are grossly intact. DTRS are +3 in upper extremities and lower extremities. Romberg is negative. RAMs are negative. Gait is steady. Musculoskeletal: FROM and strength of 5/5 in all extremities. CRITICAL THINKING What is the most likely differential diagnosis in this case and why? __Hyperthyroidism__Hypothyroidism__Menopause__Pregnancy__Anxiety/depression__Infection Which diagnostic tests are required in this case and why? __TSH__CBC__CMP__HCG__CXR__Radionucleotide uptake scan with iodine (RAI)__Ultrasound of thyroid__FSH__T3__T4__Free T4__Thyrotropin receptor antibody (TRAb)__Antithydroperoxidase antibody (TPO)__ANA__LDL__HDL What is the plan of treatment? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Insomnia 171 What is a likely diagnosis if this patient returns with severe tachycardia, confusion, vomiting, diarrhea, high fever, and dehydration? What if this patient's lab results return and the TSH is low with normal results for free T4 and T3?Would the plan be any different if Iris were unemployed?Are there any standardized guidelines that should be used to assess and treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Men's Health Case 7. 1 Fatigue 175 By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 7. 2 Testicular Pain 179 By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 7. 3 Prostate Changes 181 By Clara Gona, Ph D, FNP‐BC, RNSection 7 | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
175 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Fred, a 62‐year‐old male, presents to the primary care clinic with the chief complaint of fatigue. Upon further questioning, he also reports some difficulty concentrating and a decreased sex drive. Further review of symptoms reveals dry skin, left‐knee weakness, occasional heartburn, poly-uria, and wheezing on exertion. He denies chest pain or palpitations. He reports being on antide-pressants in the past but did not take them as directed. He is easy to get along with, forthcoming in his complaints, and describes his fatigue as a little bit more pronounced in the past couple of months. He also complains of erectile dysfunction, which he has noticed is worse in the past few years, especially since his diabetes is out of control. Past medical and surgical history: Significant for uncontrolled type 2 diabetes, insulin dependent. The patient reports a last hemoglobin A1c of 10. 2. He also has hypertension, gout, obstructive sleep apnea (with refusal to wear CPAP), and hyperlipidemia. His past surgical history includes a deviated septum repair 20 years ago. Family history: Fred's mother died at the age of 81 of Parkinson's disease; his father died at the age of 56 of Hodgkin's lymphoma; and he has 1 sister who is alive and well at the age of 58. Screening: He had a negative colonoscopy in 2008. His most recent PSA value was 3. 1 in 2007. Social history: Fred reports drinking 2 drinks of hard liquor daily. He quit smoking 20 years ago and drinks 4 cups of coffee daily. He reports not adhering to his prescribed diabetic diet and has many financial and marital stressors at home. He is self‐employed with some college education. Medications:Humalog, 75/25, 20 units in the morning and 20 units at night Nexium, 40 mg daily Crestor, 10 mg daily Allopurinol, 300 mg daily Trazodone, 150 mg at night Lopid, 600 mg twice daily Case 7. 1 Fatigue By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
176 Men's Health Baby aspirin, 81 mg daily Micardis, 40/12. 5 daily Actos, 30 mg daily Allergies: Fred has no known drug, food, or environmental allergies; and his immunizations are up to date. OBJECTIVE Vital signs: T: 98°F; P: 72; RR: 20; B/P: 138/90. His weight is 312 lbs, and his height is 58 inches. General: He has a very pleasant attitude. He is a morbidly obese male, calm, pleasant, and in no acute distress. Skin: His color is pale. His skin is clear. Small senile keratosis is noted on his left arm. HEENT: Negative. Neck: He appears to have short neck syndrome. He has no palpable nodes, no JVD. Cardiovascular: Regular rate and rhythm. S1 and S2 are normal. Respiratory: Chest is clear to auscultation. Abdomen: Obese, nontender; and bowel sounds are present. Musculoskeletal: Full range of motion. Genital: He has normal genitalia. There is no evidence of swelling. His testicular exam is normal, and there is appropriate hair growth. CRITICAL THINKING Which diagnostic studies should be considered to assist with or confirm the diagnosis?___CBC___Comprehensive metabolic panel___Lipid profile___Urinalysis with microalbumin and microanalysis___Total serum testosterone___Free serum testosterone___FSH and LH___Gonadotropin___Prolactin___Transferrin saturation___Hemoglobin A1C What is the most likely differential diagnosis and why? ___Primary hypogonadism___Secondary hypogonadism___Sexual dysfunction___Depression___Parkinson's disease | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Fatigue 177 What is the plan of treatment? What is the plan for referrals and follow‐up?What would be relative and absolute contraindications to the treatment plan of testosterone therapy? Are there standardized guidelines that would help in this case? NOTE: The author would like to acknowledge the contributions of Geraldine F. Marrocco, Ed D, APRN, CNS, ANP‐BC and Amanda La Manna, RN, ANP to this case in the first edition of this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
179 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Richard is a 45‐year‐old male who is an established patient. He arrives at the primary care office with the chief complaint of “extremely painful” right testicular pain for 3 hours. He reports no history of trauma. He reports that the pain came on gradually over the last 3 hours and is associ-ated with some mild dysuria, but no urethral discharge. Pain is described as a 9 on a 0-10 scale. He denies fever, nausea, or vomiting. He reports a loss of appetite due to extreme pain. Past medical/surgical history: Significant for COPD, GERD, hypertension, and chronic tendonitis in right elbow since fracture in 2007. He also reports a gastrointestinal infection that responded very well to Cipro. His past surgical history includes only a cervical laminectomy in 1996. Family history: His mother is alive at the age of 87 and has diabetes mellitus type 2. His father died at the age of 79 from leukemia and prostate cancer. He has 4 sisters and 2 brothers who are all alive and well. Social history: Richard works as a plumber and has been married for 20 years. He reports being in a monogamous sexual relationship with his wife. He lives in a single‐family home and has smoked 1 pack of cigarettes per day for the past 30 years. He denies alcohol or substance use and drinks tea daily. Medications:Nexium, 40 mg in a. m. Advair Inhaler, 250/50 1 puffs twice daily Atacand, 16/12. 5 mg Spiriva inhaler, 1 puff daily Allergies: No known drug allergies, but has seasonal allergies and an allergy to peanuts. Case 7. 2 Testicular Pain By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
180 Men's Health OBJECTIVE General: Visibly grimacing and teary eyed, not smiling. His skin is flushed. Vital Signs: T: 98. 2°F; P: 80; BP: 136/84; RR: 18. Respiratory: CTA bilaterally. Cardiac: RRR: S1/S2; no murmurs, clicks, gallops, or rubs. Genitourinary: Scrotal exam reveals obvious edema and redness of the right scrotal area. The area is very painful to touch or lift. There is no evidence of urethral discharge. The testes are tender to palpation; but the position of the testes is consistent and normal. When in the supine position, with elevation of the testes, Richard notes a slight decrease in pain, which is called Phren's sign. Transillumination of the testes is negative for masses. He has a normal cremasteric reflex. There are no inguinal hernias. The rectal exam reveals some prostate tenderness. CRITICAL THINKING What is the most likely differential diagnosis and why?__Sexually transmitted infection__Testicular torsion__Epididymitis__Testicular tumor__Trauma Which diagnostic studies should be considered to assist with or confirm the diagnosis? __Doppler ultrasound__Urinalysis__Urine culture and sensitivity__Gram stain__Urine for gonorrhea and chlamydia What is the plan of treatment?Are there any referrals or follow‐up care needed? NOTE: The author would like to acknowledge Geraldine F. Marrocco, Ed D, APRN, CNS, ANP‐BC, who wrote the original version of this case in the first edition of this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
181 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Stanley is a 64‐year‐old Black male who has been at the clinic regularly for health maintenance. He had an unremarkable physical exam 10 months ago. Routine labs, including a CBC, lipid profile, stool for occult blood, and EKG, were normal. He called requesting to be seen by his primary care provider because he has been having some “personal problems. ” He refused to dis-close the nature of the problem and only wants to see his regular provider. On further questioning Stanley reports problems with urination over the past 6-8 months. The symptoms are getting worse. He reports occasional “leaking” of urine after urination that has been embarrassing. He also reports getting up at least 3 times a night to urinate. Sometimes he has difficulty initiating urination and reports a weaker than usual urinary stream. On further question-ing he reports urinary urgency and occasional urinary frequency but denies pain or burning on urination, blood in the urine, abdominal pain, fever, discharge from his penis, or sexual dysfunction. Past medical history: Osteoarthritis in both knees; insomnia. Past surgical history: None. Family history: Stanley's father had diabetes mellitus Type 2 and high blood pressure; his brother has prostate problems. His mother has stage 2 dementia. Social history: Stanley is a retired teacher and has been married to his wife Ella for 42 years. They have 2 sons and 10 grandchildren. He does not smoke, but does drink 2 shots of Cognac on most nights. Medications: Ibuprofen as needed; Benadryl PRN for sleep. Allergies: NKDA. Case 7. 3 Prostate Changes By Clara Gona, Ph D, FNP‐BC, RN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
182 Men's Health OBJECTIVE General: Stanley is sitting in a chair, in no acute distress. Vital signs: Weight is 175 lbs; height is 5 ft 10 inches; oral temperature is 98. 5°F; BP is 125/80; heart rate is 74; respirations are 14. Cardiac: Regular rate and rhythm, no murmurs. Pulmonary: Clear to auscultation in all areas. Abdomen: Positive bowel sounds in all quadrants, soft and nontender on palpation. Genitourinary: No suprapubic tenderness; bladder nonpalpable. Symmetric, enlarged, nontender prostate without nodules. No discharge from penis. Neuro: Anal sphincter is normal tone, normal perineal sensation. CRITICAL THINKING What tool might be useful to evaluate Stanley's symptoms?What are the top three differential diagnoses in this case and why?Which diagnostic tests are required in this case and why?What are the concerns at this point?What is the likely diagnosis?What is the plan of treatment?What are the plans for referral and follow‐up care?What health education should be provided to this patient?Does the patient's psychosocial history impact how you might treat him?Are there any standardized guidelines that should be used to treat this case? If so, what are they? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
General Adult Health Case 8. 1 Substance Use Disorder (SUD) 185 By Jason R. Lucey, DNP, FNP‐BC Case 8. 2 Foot Ulcer 187 By Susan M. Jussaume, MSN, APRN, FNP‐BC, AHN‐BC Case 8. 3 Abdominal Pain and Weight Gain 191 By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 8. 4 Burning Leg Pain 195 By Antonia Makosky, DNP, MPH, ANP‐BC, ANP Case 8. 5 Difficulty Breathing 197 By Rebecca Hill, DNP, RN, FNP‐C, CNE Case 8. 6 Burning Epigastric Pain after Meals 199 By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 8. 7 Chest Pain with Dyspnea without Radiation 201 By Rebecca Hill, DNP, RN, FNP‐C, CNE, and Leslie Neal‐Boylan, Ph D, APRN, CRRN, F AAN, FARN Case 8. 8 Chest Pain with Radiation 205 By Rebecca Hill, DNP, RN, FNP‐C, CNE Case 8. 9 Persistent Cough and Joint Tenderness 207 By Rebecca Hill, DNP, RN, FNTP‐C, CNE Case 8. 10 Morning Headache` 209 By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 8. 11 Facial Pain 211 By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, F ARNSection 8 | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
184 General Adult Health Case 8. 12 Fatigue, Confusion, and Weight Loss 213 By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 8. 13 Hand Numbness 217 By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 8. 14 Chronic Diarrhea 221 By Clara M. Gona, Ph D, FNP‐BC, RN, and Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 8. 15 Intractable Pain 223 By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 8. 16 Wrist Pain and Swelling 225 By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, F ARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
185 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Chan Ming, a 26‐year‐old woman, presents with her partner requesting assistance to “get off pills. ” She reports a gradual progression from “partying” with alcohol and marijuana, starting at age 15, to using opioids, leading to a variety of legal and social problems. She has tried to quit on her own but experiences withdrawal symptoms (nausea, diarrhea, chills, runny nose, achiness). Past medical history: Attention‐deficit hyperactivity disorder (ADHD) (diagnosed at age 10), anxiety. Past surgical history: Right knee anterior cruciate ligament repair (at age 24). Family history: Father, age 48, is “alcoholic”; paternal uncle, age 43, has depression and has attempted suicide. Social history: Chan Ming works at a local gym but recently lost her job due to repeated tardiness and absences. She was going to community college until about 6 months ago but stopped due to poor grades and financial restrictions. She used to smoke about 1 pack per day of cigarettes but transitioned to vaping nicotine pods about 3 months ago. She reports drinking alcohol (6-8 drinks) multiple days per week (Thursday-Sunday). She also reports near‐daily cannabis use (smokes or vapes 1-2 “bowls” daily at night). For the past 2 1/2 years, she reports she has been taking “pills” (hydrocodone, oxycodone) daily. Initially, she was given prescriptions for these medicines due to knee pain and post‐surgical pain but during a later visit, she reports that she is now purchasing them illicitly. She also reports that within the past month, she began snorting “heroin” (likely fentanyl, based on regional prevalence) because the price of pills was so high, and she was having severe withdrawal symptoms when she tried to cut back and stop on her own. She reports that when she finally admitted how often she was using these drugs and how she was unable to stop on her own, her partner became scared and insisted that they needed help. Medications: Methylphenidate extended‐release, 60 mg daily. Allergies: NKDA. Case 8. 1 Substance Use Disorder (SUD) By Jason R. Lucey, DNP, FNP‐BC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
186 General Adult Health OBJECTIVE General: Chan Ming appears restless, irritable, and mildly diaphoretic. Vital signs: Heart rate is 105 beats per minute. Blood pressure is 136/88 mm HG. Respiratory rate is nonlabored and 20 breaths per minute. Temperature is 98. 7° F. Skin: Mild diaphoresis (clammy skin) is present. There are no rashes, bruises, or areas of redness. HEENT: Skull is normocephalic. Pupils are 3 mm, round, and reactive. Conjunctivae are moist. There is no icterus. There is mild rhinorrhea in both nares. Otherwise, the remaining HEENT exam is unremarkable. Neck: There is no jugular venous distention, thyromegaly, or any palpable lymph nodes. Cardiac: Mild tachycardia (rate 105) is present. Rhythm is regular. There is no murmur, rub, or gallop. Respiratory: Lungs are clear to auscultation. Abdomen: Abdomen is nontender. There is no hepatosplenomegaly. Neurologic: Cranial nerves 2-12 are intact. Romberg sign is negative. Gait is smooth and coordinated. CRITICAL THINKING What are the top three differential diagnoses in this case and why? Which diagnostic tests are required in this case and why?What are the concerns at this point?What are the options for the medicinal management of acute opioid withdrawal?What are the three FDA‐approved medicines for maintenance therapy for opioid use disorder (OUD) and which may be prescribed in primary care? What are health promotion/health prevention/harm reduction topics that should be addressed with this patient? What is the plan of treatment?What are the plans for referral and follow‐up care?What health education should be provided to this patient?What demographic characteristics might affect this case?Does the patient's psychosocial history impact how you might treat him?What if the patient lived in a rural (or urban) setting?Are there any standardized guidelines that should be used to treat this case? If so, what are they?What other professionals might you collaborate with to best provide comprehensive care for substance use disorder? If you discovered that the patient was using substances intravenously, what other concerns/ testing/treatment would you want to consider? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
187 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE George is a 62‐year‐old gentleman presenting to primary care with complaints of newly developed right great toe pain with redness, swelling, and discharge. One week ago, while George was performing his routine foot care, he decided to remove a callus on the bottom of his right great toe. The callus had a lifted edge and the patient thought it would be better removed so as to not catch the skin and have it tear away. After gently pulling away the callus using tweezers George noted the skin underneath to be pink and intact. He reports the region where the callus had been removed was visibly indented slightly below the surrounding dermis. Five days ago George began to develop tenderness and pain (6/10) on the underside of his right great toe with weightbearing and walking activity. George wrapped the toe with a gauze dressing in an effort to pad the great toe, thinking this would help him with pain management while he went about his daily activities. Three days ago, George noted increasing pain and redness in the right great toe and he now had a scant amount of blood‐tinged discharge on the dressing when he took the dressing off that evening. George continued with self‐care, washing the affected great toe with antibacterial soap daily, applying a clean, dry gauze dressing during daytime hours and open to air at bedtime. The pain and redness continued and discharge was becoming more abundant. Now, George reports that within the past 24 hours his pain has increased to a 8/10, redness is extending to lateral regions of the great toe with swelling, and he notes the discharge during the evening dressing removal has changed to yellow and blood tinged. George, concerned about worsening symptoms, presents today for evaluation of the right great toe wound. Family history: Heart disease: PGM, PGF, MGM, MGF, mother, father, and brother; peripheral vascular disease (PVD): mother, brother; hypertension: mother, brother; stroke and TIAs: mother; colon cancer: PGM; colitis: mother; ovarian cancer: mother; diabetes mellitus Type 2: MGM, mother; brain aneurysm: PGF. Past medical history: Idiopathic thrombocytopenic purpura (ITP) (chronic type), diagnosed at age 33; low back pain (three herniated discs auto accident rear‐ended) age 35; duodenal ulcer (resolved), diagnosed at age 40; diaphragmatic hernia, diagnosed at age 40; mixed hyperlipidemia, diagnosed Case 8. 2 Foot Ulcer By Susan M. Jussaume, MSN, APRN, FNP‐BC, AHN‐BC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
188 General Adult Health at age 48; diabetes mellitus Type 2, diagnosed at age 50; peripheral vascular disease, diagnosed at age 53; sleep apnea, diagnosed at age 53; heart disease (peripheral arterial disease and mild aortic stenosis), diagnosed at age 60. Social history: George is 62 years old, married for 42 years, father of 4 adult children and grandfather of 4 grandchildren. He is a college graduate and has been employed 49 years in a professional, white‐collar position. He has spent most of those years in an executive managerial position, working 40‐plus hours weekly. There have been no known occupational hazards or chemical exposures. George is active in his community and a practicing Catholic who attends weekly services. His hobbies include fine woodworking and professional cooking. He says his interpersonal relationships are satisfying and supportive. George reports that his finances are very good; he lives an upper‐middle‐class lifestyle. George lives in a single‐family home in a safe to moderately safe suburban neighborhood. He has never smoked. He rarely drinks alcohol and when he does, he drinks wine. Medications: Atorvastatin, 80 mg one tablet PO at bedtime Irbesartan, 150 mg one tablet daily Lantus (insulin pen), 12 units SQ daily Metformin HCL, 1,000 mg one tablet PO twice a day with meals Torsemide, 20 mg one tablet daily every morning Potassium chloride ER, 20 MEQ two tablets daily every morning Epipen, as directed PRN for bee sting aller gy/anaphylaxis Senna (stool softener), one tablet daily as directed Multivitamin (Centrum Silver), one tablet daily every morning Vitamin D3, 2,000 IU one tablet every morning with a meal Osteo Bi‐Flex (glucosamine chondroitin), 750 mg two tablets daily Ultra Co Q10 (Qunol brand), 100 mg one soft gel daily Tylenol Extra Str ength, 500 mg two tabs daily as needed for pain Kaprex (selective kinase r esponse modulator), 350 mg one soft gel daily for low back pain Allergies:Prednisone/steroids (high doses cause significant muscle weakness). Bee sting - Anaphylaxis - carries Epipen and has allergy notification in wallet. No known food allergies. Immunizations: Up to date. OBJECTIVE George is a well‐developed, well‐nourished adult male in no acute distress. He is dressed appro-priately for the season with excellent hygiene. He is alert and oriented times three. George is engaging and interactive; his speech is clear and articulate. George's gait is steady, but he walks bearing weight on the outer edge of the right foot; his posture is upright. Vital Signs:Height: 6 ft 5 inches; weight: 298 lbs (BMI = 35. 3); temperature: 98. 9°F (temporal); pulse: 84/minute (apical) RRR; respirations: 16 BPM (breaths per minute); blood pressure: 118/72; pulse xx: 99% on room air; pain: 6/10 (foot pain/right great toe). | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Foot Ulcer 189 Integumentary: Intact without rashes or lesions; warm and dry. There are scattered varicosities on the legs bilaterally. There is brownish discoloration to the skin of the lower legs bilaterally, predominantly over the shins and dorsum aspects of the feet. There is no edema. Right great toe: Plantar aspect of right great toe reveals broken skin integrity with a wound of 2. 0 cm × 1. 5 cm (length × width), a depth of 2-3 mm. There is a small amount of serosanguinous dis-charge, some yellow crusting on the edges of the wound; mild redness and swelling are noted on the lateral regions of the right great toe. The toe is warm and tender to palpation. The patient reports pain at 6/10 with passive and active ROM. HEENT:Eyes: PERRLA, EOMs intact, visual acuity grossly intact. Ears: External canals patent, TMs pearly gray, intact. Hearing is intact to whispered voice 3 feet bilaterally. Nares: Patent, pink mucosa intact; inferior turbinates visible, no discharge. Throat: Oral mucosa pink, tongue well papulated, no lesions; no swelling or exudate in pharynx; teeth in good repair. Respiratory/Thorax: Easy breathing, no use of accessory muscles, no retractions. Lungs clear throughout all fields, no crackles, no wheezes. Cardiac: No lifts or heaves visible; S1, S2 RRR, without murmurs, clicks, gallops, or rubs. PV: Pulses 2+ bilaterally (brachial, radial, dorsalis pedis, and posterior tibial). Abdomen: Moderately protuberant, soft nontender throughout, tympany predominant, normoac-tive bowel sounds all 4 quadrants, no tenderness, Blumberg's negative, no guarding. Musculoskeletal: Tenderness to palpation and moderate pain with ROM of right great toe joint. Full ROM of all major joints, upper and lower extremities Neurological: Cranial nerves I-XII grossly intact, alert and oriented ×3, gait steady and balanced, alternating arm swings. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___CBC with differential___HBA1c___CMP___Blood cultures___X‐ray (right foot)___MRI (right foot) Identify and explain three differential diagnoses. ___Diabetic foot ulcer___Nonhealing skin wound with secondary bacterial infection___MRSA infection___Cellulitis with or without osteomyelitis What is the plan of treatment? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
190 General Adult Health Are there any standardized guidelines to consider? What health education should be provided to the patient?What complicating factors specific to this case should be considered?What collaborative assessment and care might the patient require? Include your rationale. ___Referral to a wound specialist___Referral to Podiatry___Visiting nurse with a wound specialist nurse for follow‐up with home care___Orthopedic or physical therapy consult | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
191 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Annette, a 28‐year‐old female, presents to the primary care practice for an initial visit. She presents with two major concerns. First, she is concerned because she was told she had gallstones by ultra-sound and was advised by another primary care provider (PCP) that she needed her gallbladder removed. She has had several bouts of abdominal pain and some dyspepsia, but no nausea, vomit-ing, diarrhea, or any other gastrointestinal symptoms. She points to an area in her abdomen that has been painful, especially when she eats high‐fat foods. She has no other gastrointestinal complaints. Her second complaint is weight gain. Her diet has not changed over the past few years; however, she has noticed a change in the way her clothes fit as well as a 15‐pound increase in her weight over the past year. Also over the past year, she has had irregular menses. She often “skips months,” and she reports 7 cycles of menstruation over the past year. When she does have her period, “it lasts for over 2 weeks. ” At one point she did not have a period for 3 months, and she thought that she might be pregnant. Her review of systems is negative except for increased hair growth across the sides of her face, her chin, and the middle of her chest, arms, and upper thighs, which she has had since she was an adolescent. She also complains of acne. Further review of systems reveals no dizziness, no headache, no problems with her vision, no ringing in her ears; she is not short of breath. She has no complaints of cough, no palpitations, no chest pain. She has no genitourinary complaints. She has no musculoskeletal complaints. She has no weakness, no paresthesia, and no numbness or tingling of the extremities. Past medical history: Noncontributory. Past surgical history: None. Family medical history: Annette's mother has Type 2 diabetes and hypertension. Her father died at age 50 due to lung cancer and had a positive smoking history. Her brother is alive and well at age 26, and her sister is alive and obese at age 22. Social history: Annette was born in Brazil and reports no tobacco, alcohol, or substance abuse. She drinks 1 cup of coffee daily and lives at home with her mother, brother, and sister in a single‐family home in a suburban town. She works full‐time as an administrative assistant and is a Case 8. 3 Abdominal Pain and Weight Gain By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
192 General Adult Health part‐time student finishing a bachelor's degree in science at a state college. She has a network of friends and family and her hobbies include traveling and theater. She is currently in a sexual rela-tionship with 1 partner and does not practice any form of contraception. Her LMP was 2 months ago, and her last Pap smear was 4 years ago and negative. Medication and allergies: She has no medication allergies but reports allergies to pork and cats. She is not on any regular medications but takes Tylenol 2 tablets as needed for headache (approx-imately twice a week). Her immunizations are up to date. OBJECTIVE Vital signs are within normal limits with a blood pressure of 110/80 and a temperature of 98. 2°F. Pulse is 76 and regular, and respiratory rate is 18. Height is 62 inches, and weight is 200 lbs (BMI 36. 6). Annette is a well‐developed, obese female who is in no acute distress. She is coherent, alert, and pleasant. Skin: She has fine, dark hair on her chin and on the sides of her face. There is increased hair growth on her forearms, sternal area, and upper thighs. Acne is present on her forehead and lateral cheeks bilaterally. Neck: Goiter, thyroid is palpable, nontender; no nodules are palpable or appreciated. Neck is supple and without lymphadenopathy. Respiratory: Her lungs are clear, and the chest is symmetrical. Cardiac: Regular heart rate and rhythm. S1 and S2 are present and normal. Abdomen: Obese and soft; bowel sounds are present; and there is tenderness in the epigastric area. Liver and spleen are nonpalpable. Musculoskeletal: Extremities are without edema. There is full range of motion and good strength. Carotid, femoral, dorsalis pedis, and post‐tibial pulses are all +2. Neurologic: DTRs are 2+ in the biceps, triceps, brachioradials, patella, and Achilles. Cranial nerves II-XII are grossly intact. CRITICAL THINKING Which diagnostic studies should be considered to assist with or confirm the diagnosis?___Androgen elevation, testosterone level___Lipids___LH___FSH___Insulin level___Urea breath test___Serum H. pylori ___TSH, free T4___LFTs___HCG___Vitamin D___HIV | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Abdominal Pain and Weight Gain 193 ___Urinalysis ___Transvaginal ultrasound___Abdominal ultrasound___CBC with differential___Metabolic panel___Prolactin level___DHEA What are the most likely differential diagnoses and why? ___Gastroesophageal reflux disease (GERD)___Cholecystitis___Helicobacter pylori infection/peptic ulcer disease___Polycystic ovarian syndrome (PCOS)___Hypothyroidism___Hyperprolactinemia What is the plan of treatment?Are any referrals or follow‐up needed?What if the patient had a positive pregnancy test?What if the patient were trying to conceive?Are there any standardized guidelines that should be used to assess or treat this case? NOTE: The author would like to acknowledge Geraldine Marrocco, Ed D, APRN, CNS, ANP‐BC who write the case for the first edition of this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
195 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Robert is a 74‐year‐old gentleman who resides in an assisted living facility. He was referred today by the visiting nurse for evaluation of right leg pain and a new ulcer on the right lower extremity for the past week. The pain is worse when he has his feet up at night for sleep. He describes the pain as “burning,” not associated with exercise. The pain improves if he dangles his legs at night. In the daytime, the pain is unchanged if he sits or stands. He is unable to walk very far and uses a walker. He reports having lower extremity swelling for several years. Robert says he is feeling okay today. He reports chest pain “when I get upset about something” although not with exertion. He denies shortness of breath or palpitations. He reports urinary fre-quency and alternating constipation (most of the time) and diarrhea (if he takes too much medi-cation for constipation). He is not sexually active. Past surgical history: Aortic valve replacement Past medical history: Notable for hypertension; he is a former smoker (40 pack‐years). Robert has Type 2 diabetes mellitus, hyperlipidemia, mitral stenosis, atherosclerosis of the coronary arteries, carotid stenosis, atrial fibrillation, constipation, neuropathy of the left hand and both feet, lower extremity edema, and heart failure with preserved ejection fraction (HFp EF). Robert is obese. He ambulates with a walker. Family history: Robert's father has hypertension and coronary artery disease; his mother and brother are both obese and have Type 2 diabetes mellitus. Social history: Robert describes himself as having a learning disability. He worked as a garbage collector for many years. His brother visits him at the assisted living apartment building and helps with clothes shopping and other necessities. Robert is well known to visiting nurses for blood pressure checks and medication management. Robert denies alcohol or illicit or recreational drug use. He does not currently have a romantic partner. He enjoys his meals at the assisted living community. Medications: Acetaminophen, aspirin, atorvastatin, docusate sodium, furosemide, gabapentin, lisinopril, insulin detemir (long acting), insulin lispro (short acting), metoprolol, multivitamin, miralax, ranitidine, warfarin. Allergies: Oycodone: mental status change. Case 8. 4 Burning Leg Pain By Antonia Makosky, DNP, MPH, ANP‐BC, ANP | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
196 General Adult Health OBJECTIVE General: Unshaven. Well developed, well nourished. Afebrile and in no distress. Vital Signs: BP: 138/64; heart rate: 68 and regular; RR: 18 and regular; Temp: 97. 7°F; Sp O2: 100%. Skin: Tattoos are noted on upper and lower extremities. Lower extremities are almost hairless on the lower legs and feet. HEENT: Head is normocephalic and nontender. Pupils are equal, round, and reactive to light; EOMs intact. Ear canals clear with TMs intact. Nares patent. Oropharynx is clear with no masses or exudate. Poor dentition. Neck: Carotids with 2+ bruits bilaterally. No JVD. No lymphadenopathy. Thyroid nonpalpable. Cardiovascular: AP 68, RRR. Mechanical click appreciated on auscultation. Upper extremity pulses 1+. Femoral pulse is palpable. Popliteal pulse difficult to palpate. Lower extremity pulses are nonpalpable. Abdomen: Soft. Obese. Nontender. No bruits. Bowel sounds present. No AAA or organomegaly, although exam is limited due to body habitus. Extremities: Lower legs with dependent rubor. 1 cm well‐demarcated open ulcer on right lateral heel. Skin is cool and dry. No clubbing. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Ankle brachial index (ABI)___Toe brachial index (TBI)___Exercise ABI___Six‐minute walk test___Arterial duplex ultrasound___Abdominal ultrasound What is the most likely differential diagnosis and why? ___Venous insufficiency___Venous stasis ulcer___Peripheral artery disease___Spinal stenosis___Nerve root compression___Diabetic neuropathy What is the plan of treatment?Are any referrals needed?What are the differences between arterial and venous disease?How should the clinician differentiate between venous ulcers and arterial ulcers? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
197 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Janis, a 59‐year‐old female, presents with tachypnea, dyspnea on exertion, and mild chest discom-fort. She was diagnosed with emphysema 4 years ago and was placed on bronchodilator therapy. She has an 80 pack‐year history of smoking. Janis states: “I feel short of breath when I walk, and my chest is sore. ” She describes her chest soreness as mild pressure, rated as 2 on a 1-10 scale. The pain is over the anterior thorax, more pronounced in the ribs, which she believes has devel-oped from coughing hard. She states that she has had a nonproductive cough for 4 days and feels more fatigued than usual. She denies fever, chills, or recent international travel. Past medical history: She has osteoarthritis in the hands and knees. She has a surgical history of appendectomy and cholecystectomy. In the past year, she has had 2 exacerbations of her COPD and has attempted to stop smoking, using nicotine gum replacement unsuccessfully. Family history: Noncontributory. Social history: She lives with her husband, who also smokes 2 packs of cigarettes per day, and cares for her elderly mother, who lives with them and is frail but ambulatory. Medications: Albuterol MDI, 90 mcg/inhalation, 2 puffs as needed every 4-6 hours; ipratropium bromide MDI, 18 mcg/inhalation, 2 puffs 4 times/day; ibuprofen, 600 mg TID as needed for arthritic pain. Allergies: Penicillins and cephalosporins (hives). OBJECTIVE General: Janis is dyspneic at rest, sitting. Use of accessory muscles evident, pursed lip breathing noted, able to speak in 3‐word sentences. Vital signs: BP: 122/64; P: 92; R: 26; T: 100. 2°F; Sp O2: 88%. AP to transverse ratio is 1:1. Skin: Warm and dry. Case 8. 5 Difficulty Breathing By Rebecca Hill, DNP, RN, FNP‐C, CNE | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
198 General Adult Health HEENT: Negative. Cardiovascular: RRR: S1/S2; no murmurs, clips, rubs, or gallops. No peripheral edema. Posterior tibial and dorsalis pedis pulses 2+/4. Respiratory: Lungs have diffuse expiratory wheezing and crackles in the right upper lobe. Tenderness to palpation along intercostal spaces on right and left anterior and lateral thorax from 2nd to 5th intercostal spaces. PFT conducted 2 months prior to visit showed obstructive flow pat-terns and reduced FEV1/FVC. Abdomen: Soft, with active bowel sounds in all quadrants. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Spirometry___Chest X‐ray___CBC___ABGs___ECG___Echocardiogram___CT of the chest What is the most likely differential diagnosis and why? ___COPD exacerbation___Pneumonia___Asthma___Pulmonary neoplasm What is the plan of treatment?What is the plan for follow‐up care?Are any referrals needed?What additional risk factors are evident for this patient?Are there any standardized guidelines that should be used to treat this patient? NOTE: The author would like to acknowledge Kathy J. Booker, Ph D, RN for her contribution to this case in the first edition of this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
199 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Meredith is a 63‐year‐old female who presents with worsening epigastric pain. She describes it as burning pain that starts over the sternum and radiates upward to her neck. The pain occurs approximately 30-45 minutes after every meal and continues for about 4. 5 hours thereafter. Heavy meals, coffee, and spicy foods make the discomfort worse; she is most uncomfortable when she lies down at night. She has to prop herself on 3 pillows every night to decrease the pain, so she refrains from eating close to bedtime. Meredith also describes a sour taste in her mouth when she lies down and has awakened occasionally with coughing and regurgitation. The pain has been worsening over the past 3 months and occurs daily. The discomfort interferes with her quality of life. She has had some mild relief with Maalox and Tums. Meredith also reports an intermittent nonproductive cough and feeling hoarse when she talks. She denies any fevers, chills, dysphagia, odynophagia, weight loss, fatigue, shortness of breath, abdominal pain, nausea, changes in bowel habits, blood in the stool, or urinary symptoms. Past medical history: Hyperlipidemia. Family history: Noncontributory. Social history: Meredith has smoked 1/2 ppd for 30 years; drinks a bottle of wine by herself each Friday and Saturday night. She has a history of marijuana use when in college but none currently. She is widowed and works as an elementary school teacher. Medications: HCTZ, 12. 5 mg PO daily; Lipitor: 10 mg. Allergies: Penicillin. OBJECTIVE General: Meredith is well appearing, in no apparent distress, and is moderately obese. Vital signs: She is afebrile. BP is 160/100. HR is 86 and regular. Respirations are 14 and regular, and oxygen saturation is 96% on room air. Case 8. 6 Burning Epigastric Pain after Meals By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
200 General Adult Health HEENT: Unremarkable except for some moderate erythema in the posterior pharynx and some dental erosion. Her teeth are stained, as well. There are no abscesses. Neck: There is no cervical lymphadenopathy, and the thyroid is nonpalpable. Carotids are +2 without bruits. Cardiac: Regular rate and rhythm without murmurs, clicks, gallops, or rubs. Respiratory: Lungs are clear bilaterally. Abdomen: Soft and obese without bruits; positive bowels sounds. There is mild epigastric tender-ness on palpation but without rebound guarding. There is no organomegaly. Rectal: Brown stool with a trace of positive on guaiac testing. Skin: No rashes, lesions, or ulcers. CRITICAL THINKING What is the most likely differential diagnosis and why? ___Angina___Myocardial infarction___Gastroesophageal reflux disease (GERD)___Gastric ulcer___Duodenal ulcer___Cholecystitis___Gastrointestinal bleed Which diagnostic studies should be considered to assist with or confirm the diagnosis? ___CBC with differential___Metabolic panel___Liver function tests___Urinalysis___ECG___Chest X‐ray___H. pylori testing___Endoscopy___Colonoscopy___FIT test___Esophageal manometry and p H monitoring___Lipids What is the plan of treatment?What is the plan for referrals and follow‐up?What are the patient's risk factors for this condition?What are the possible complications of this condition? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
201 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Zachary, a 60‐year‐old man, presents to the primary care office with sharp chest pain relieved by leaning forward. Zachary reports that he has had increasing chest pain over the past 3 days. His pain is rated as +5/10 and is accompanied by dyspnea, especially when walking. His pain is less-ened by sitting upright and leaning forward. He has no radiation of the pain to his jaw, back, or arms. He denies cough or recent international travel. With the development of the dyspnea and a mild fever, he became worried and sought treatment. Past medical history: Zachary has been well for the past 2 years, aside from a recent upper respiratory infection (2 weeks ago) and a history of gout. Family history: His father died at age 58 of an MI. His mother had COPD and died at age 75. Social history: He works as a commodities broker. He commutes to the city daily from out of state and is married and has 3 children, ages 16-25. He is a nonsmoker. He drinks 2-3 beers every evening. Medications: Zachary is on allopurinol, 300 mg daily, for gout and takes ibuprofen regularly for joint stiffness and pain in his right elbow and both knees. He also takes a daily Ecotrin and sup-plemental glucosamine. Allergies: No known allergies. OBJECTIVE General: Zachary is dyspneic at rest. He is completely upright and sitting forward on the exam table. His color is ashen. Vital signs: BP: 142/94; P: 92; R: 28; T: 100. 8°F. Height is 6 ft 4 inches. Weight is 247 lbs. Skin: Cool and dry. Case 8. 7 Chest Pain and Dyspnea without Radiation By Rebecca Hill, DNP, RN, FNP‐C, CNE, and Leslie Neal‐ Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
202 General Adult Health HEENT: Negative. Cardiovascular: He has 6‐cm jugular venous distention at 90 degrees. Heart tones: S1/S2 strong, with audible pericardial friction rub; no murmurs. He has trace ankle edema. Pedal and posterior tibial pulses are 1+/4. Respiratory: CTA bilaterally. An ECG is obtained (Figure 8. 7. 1). CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Measure blood pressure for pulsus paradoxus___Repeat ECG___Echocardiogram___CBC with differential___Electrolytes__ Lipids___Blood glucose___LFTs___TSH___BUN and creatinine___PT and INR Figure 8. 7. 1 Zachary' s ECG. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Chest Pain and Dyspnea without Radiation 203 ___Urinalysis ___Sedimentation rate___Serial troponins (stat, 12 and 24 hours)___Cardiac catherization___Chest X‐ray___Cardiac MRI What is the most likely differential diagnosis and why? ___Acute myocardial infarction (MI)___Pericarditis___Infectious cardiomyopathy What is the plan of treatment?What is the plan for follow‐up care?Are any referrals needed?What if this patient had recently sustained an acute myocardial infarction?Are there any standardized guidelines that should be used to assess/treat this case? NOTE: The author would like to acknowledge Kathy J. Booker, Ph D, RN for her contribution to this case in the first edition of this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
205 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Oliver, a 48‐year‐old male, presents to the office with mild‐to‐moderate chest pressure with radi-ation to his back. Oliver reports that he was awakened from sleep at 7:00 a. m. with chest pressure, initially described as soreness across his anterior chest and through to his back. He rates his pain as +6/10. He felt as though, if he could just belch, he would feel better. He also reports a nonpro-ductive cough for the past 2 days. His wife drove him to the office to be here when it opened at 9:00 a. m. She tried to convince Oliver to go to the emergency room, but he emphatically refused, insisting on going to the office first. Upon arrival to the office, Oliver is escorted to an examination room and the receptionist is instructed to call 911. Past medical/surgical history: Diabetes mellitus Type 2. Oliver's last hemoglobin A1c 2 months ago was 7. 4%. Family history: He has a family history of premature coronary artery disease. His father died of acute myocardial infarction (AMI) at age 45. One brother died of AMI at age 49. Social history: He has smoked for 25 years but has reduced his smoking to 1 pack per day since his brother's death 2 years ago. He has put on 25 pounds in the past 2 years and is generally sedentary. Medications: Metformin, 500 mg once daily. Allergies: Latex (anaphylaxis). OBJECTIVE General: Oliver is anxious and shows Levine's sign as you enter the examination room. He is slightly diaphoretic. He took one oral aspirin (325 mg) on the way to the office. Vital signs: BP: 192/96; P: 102; R: 22; T: 97. 8°F. His Sp O2 is 90%. ECG: His ECG shows ST‐segment depression and T‐wave inversion in leads II and III. Case 8. 8 Chest Pain with Radiation By Rebecca Hill, DNP, RN, FNP‐C, CNE | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
206 General Adult Health Cardiovascular: His heart tones are muffled with an S3 gallop. His hands and feet are cool on palpation. Radial pulses are 2+. Pedal and posterior tibial pulses are 1+. He has jugular vein dis-tention of 5 cm with head of bed at 90 degrees. He has no carotid bruits, heaves, or thrusts. His PMI is at the 5th ICS, left mid‐clavicular line. Respiratory: He has harsh rhonchi in the upper lobes bilaterally. CRITICAL THINKING What is the most likely differential diagnosis and why? ___Acute coronary syndrome___Pulmonary embolism (PE)___Gastroesophageal reflux Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Electrocardiogram___Troponin___Hemoglobin and hematocrit___Electrolytes___BUN and creatinine___Transfer to emergency services with cardiac catheterization What is the plan of treatment?Are any referrals needed?Does the patient's family history impact how you might treat him?What are the primary health education issues?What if this patient were female?What if the patient lived in a rural, isolated setting?Are there any standardized guidelines that should be used to assess/treat this case? NOTE: The author would like to acknowledge the contribution of Kathy J. Booker, Ph D, RN to this chapter in the first edition of this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
207 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Alice, a 42‐year‐old female, presents with a persistent dry cough and joint tenderness. She was treated for an upper respiratory infection 1 month ago with only slight improvement in upper respiratory symptoms. At the time of the onset of symptoms, she also had flu‐like symptoms, including vomiting and chills, which have resolved. The cough persisted and the joint tenderness has worsened over the past week. She reports a low‐grade fever and chills, and notes that both elbows are painful with any arm movement. She reports night sweats for 1 week duration. She has been taking ibuprofen, alternating with acetaminophen, every 4 hours. She has also noted gradual dyspnea with activities. Past medical history: She has a history of breast cancer, treated with bilateral mastectomy and chemotherapy, and GERD. Family history: Noncontributory. Social history: She lives in a rural farming community in the Southeast. Medications: Omeprazole 20 mg QD, ibuprofen 400-600mg Q8 hours PO PRN, and acetamino-phen 650 mg Q6 hours PRN. Allergies: No known allergies. OBJECTIVE General: Coughing. Vital signs: BP: 122/64; P: 92; R: 26; T: 100. 8°F. Skin: Warm and dry. HEENT: Negative. Neck: No JVD or lymphadenopathy. Case 8. 9 Persistent Cough and Joint Tender ness By Rebecca Hill, DNP, RN, FNP‐C, CNE | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
208 General Adult Health Cardiovascular Heart tones bounding; no thrills, rubs, or murmurs. No peripheral edema. All pulses 3+/4. Respiratory: Bronchovesicular breath sounds audible over anterior chest; posterior breath sounds diminished. Course crackles audible in posterior bases. Harsh, nonproductive cough is evident during lung assessment. Abdomen: Soft, with active bowel sounds. Neuromuscular: Limited range of motion of elbow and wrist due to pain. Patellar deep tendon reflexes hyperactive bilaterally. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Chest X‐ray___CBC___ABGs___X‐ray___MRI___CT of chest What is the most likely differential diagnosis and why? ___Pneumonia___Bronchitis___Tuberculosis___Blastomycoses dermatitidis (BD)___Osteomyelitis What is the plan of treatment?What further diagnostic tests are needed?What is the plan for follow‐up care?Are any referrals needed?Are there any standardized guidelines that should be used to assess/treat this case? NOTE: The author would like to acknowledge Kathy J. Booker, Ph D, RN for her contribution to this case in the first edition of this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
209 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Andrew is a 42‐year‐old African American male who presents with BP 168/92 and morning head-aches. Andrew reports headaches upon arising approximately 2 times per week. This morning prompted his coming to the office for evaluation, as he felt some lightheadedness and chest tight-ness that resolved following his shower. He has never been told that his blood pressure was high, but he has not been seen in the office for 6 years. His last visit was for bronchitis and treatment with antibiotics. Past medical/surgical history: He has no surgical history. Family history: His father is deceased at age 65 from an acute MI; one brother died at age 50 with acute MI, following abdominal aortic aneurysm surgery. He has 4 other siblings in good health. Social history: Andrew has been dealing with several life issues, including the death of a child and a reduction in his work hours at a local manufacturing plant. He smokes 2 packs of cigarettes per day, leads a sedentary life outside of work, and is overweight at 6 ft 2 inches and 255 pounds (BMI = 33). He reports generally good health. His smoking history is 44 years. He is married and has 3 remaining children, ages 12, 15, and 17. His oldest son was killed in a car accident 2 months ago. He drinks moderately, generally 2-3 beers 4-5 times per week. He reports drinking more heavily on the weekends. He and his wife are active in their church. He is a high school graduate and makes approximately $50,000 annually. His wife has a full‐time position that supplements the family income to approximately $90,000. For the past 3 months, his business has experienced a downturn and there have been mandatory furlough days, which have required their family spending to be seriously curtailed, although they are able to meet their financial obligations at this time. Medications: Andrew takes a daily aspirin and a multivitamin, but he is on no prescription med-ications at this time. Allergies: No known allergies. He reports being lactose intolerant. Case 8. 10 Morning Headache By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
210 General Adult Health OBJECTIVE General: Patient appears older than his stated age; frowning. Vital signs: BP on arrival is 188/110. After 20 minutes, repeat BP is 180/90. P: 94; R: 20; T: 98. 2°F. HEENT: Cranial nerves intact. EENT exam negative. Neck: No lymphadenopathy. Skin: Skin warm and dry. Respiratory: Lung sounds vesicular over peripheral fields; harsh, bronchial breath sounds in upper lobes bilaterally; moist cough audible; no adventitious breath sounds. Cardiovascular: No jugular venous distention at 30 degree elevation. Heart sounds strong 3/4; grade 2/6 systolic murmur at left sternal border, 5th ICS. Abdominal and peripheral vascular assessments negative; pedal and post tibial pulses 2+/4+. Abdomen: Tender over right upper quadrant. Tympany predominates. Liver border WNL, spleen and kidneys nonpalpable. Neuromuscular: Romberg's sign negative; gait relaxed and symmetrical; no pronator drift. Full ROM all extremities. CRITICAL THINKING Which diagnostic studies should be considered to assist with or confirm the diagnosis?___Electrocardiogram___Troponin___CBC___Comprehensive metabolic panel___Serum cholesterol panel What is the most likely differential diagnosis and why? ___Obstructive sleep apnea___Hypertension___Dyslipidemia___Cardiovascular disease___Diabetes mellitus___COPD What is the plan of treatment?What is the plan for referrals and follow‐up care?What if this patient were female?What if this patient were also diabetic?Are there any standardized guidelines that should be used to assess or treat this case? NOTE: The author would like to acknowledge Kathy J. Booker, Ph D, RN for her contribution to this case in the first edition of this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
211 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Henry, a 32‐year‐old male, presents with a report of facial pain for 5 days. He reports that he has a headache, especially when he bends down, and that his teeth hurt sometimes. On further ques-tioning, Henry states that he had a cold about 14 days ago. He had rhinorrhea with clear drainage, mild sore throat, ear pressure, and mild headache. The symptoms cleared up after 1 week, and he felt fine, but then some of the symptoms returned about 5 days ago. Now he describes facial pain, headache upon waking, dental discomfort, and blood‐streaked thick yellow nasal drainage. His sense of smell seems diminished. He has a history of seasonal allergic rhinitis. Past medical history: Chicken pox at age 5 years; testicular torsion at age 15 years (no complications). Family history: His family is well, although his mother and sister have migraine headaches. Social history: He is happily married with 2 children. Henry works as a supermarket manager, is a nonsmoker, and denies other substance use. Medications: Advil sinus with no relief. Allergies: Seasonal hay fever. OBJECTIVE General: NAD. Vital signs: Henry is 6 ft 1 inch tall and weighs 165 pounds. His oral temperature is 99. 5°F. BP is 128/84. Pulse is 74 and regular. Respirations are 12 and regular. HEENT: Sclera are clear; PERRLA; EOMs intact. Tympanic membranes are clear and intact; there is no fluid. There is tenderness to palpation of the frontal and maxillary sinuses. Nares are ery-thematous and swollen. There is no obvious discharge. Attempts to transilluminate the sinuses Case 8. 11 Facial Pain By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
212 General Adult Health indicate an absence of light. There is cobblestoning in the throat, but no erythema. Tonsils are +2. There are no exudates. Neck: There is no lymphadenopathy, and the thyroid is nonpalpable. Cardiac: RRR, S1/S2; no murmurs, clicks, gallops, or rubs. Respiratory: Clear to auscultation. CRITICAL THINKING Which diagnostic studies should be considered to assist with or confirm the diagnosis? ___CT scan of sinuses___X‐ray of sinuses___CT scan of brain___CBC___CMP___None What is the most likely differential diagnosis and why? ___Viral upper respiratory infection (URI)___Acute sinus infection___Asthma___Migraine___Allergic rhinitis___Nonallergic rhinitis___Vasomotor rhinitis___Rhinitis medicamentosa What is the plan of treatment?What is the plan for referrals and follow‐up treatment?Is the family history of migraines relevant? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
213 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Maryanne, a 78‐year‐old female widow, presents to the primary care clinic with the chief complaint of feeling very tired lately. She also complains of some nasal congestion. She arrives with her daughter, who provides some gaps in the medical history. The daughter notes that Maryanne's fatigue has been a complaint for about 16 months. Further review of systems provided by the daughter reveals a concern that her mother seems to have slight confusion, increased fatigue, poor appetite, and a bitter taste sensation when eating. Maryanne eats 3 small meals daily, and she's had some unintentional weight loss over the past few months. She reports a marked decrease in energy level. She denies nausea, vomiting, or emo-tional lability. She does not eat red meat. Past medical history: Significant for hypertension for many years; Type 2 diabetes mellitus that is not well controlled on oral meds; high cholesterol for many years; lymphedema in lower extrem-ities bilaterally since adolescence; benign lung densities per chest X‐ray; and a report of “Mediterranean anemia. ” She had cataract removal surgery 5 years ago. She sees a podiatrist every 3 months and sees a retinologist periodically. Her last visit was today, and her exam was negative. Family history: Her mother died at age 81 with diabetes and hypertension. Her father died of lung cancer. She has two brothers, ages 81 and 83, both with hypertension and one with prostate cancer. Social history: Maryanne was born in California and has 4 children; does not use tobacco cur-rently; quit smoking over 20 years ago. She denies alcohol use or history of other substance use. She does not drink coffee and does not exercise. Her typical day includes watching television and doing housework. She lives independently in an adult community in Alabama and has a home-maker 3 times weekly. She is a retired cook. She has 1 daughter who lives nearby. Allergies: No known drug allergies and is up to date on her immunizations. Skin: Complains of dry skin. Case 8. 12 Fatigue, Confusion, and Weight Loss By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
214 General Adult Health HEENT: Denies any dizziness or blurry vision. No headaches except for + right ear pain. Sometimes has difficulty swallowing. Cardiovascular: Denies chest pain or palpitations. Respiratory: Occasional cough and has noticed more shortness of breath recently. Sleeps on 2 pillows. Gastrointestinal: Denies abdominal pain or bloating. She does not have any regurgitation. No nausea or vomiting. She has a bowel movement daily that is normal, brown in color, and normal consistency. She does not report any blood in her stool. Musculoskeletal: Reports joint pain in her knee, especially her left knee. Psyche: Generally happy, social, but most recently not engaged due to fatigue and weakness. Medications: Glucophage, 1,000 milligrams twice daily Avandia, 4 mg daily Protonix, 40 mg daily Glucotrol, 10 mg daily Aricept, 10 mg daily at night Cardia, 240 mg daily in morning Lisinopril, 10 mg daily Diovan, 160/12. 5 BID Aspirin, 81 mg daily Crestor, 5 mg daily Zetia, 10 mg daily Coreg, 12. 5 mg BID Lasix, 20 mg daily Potassium, 10 m Eq daily Actonel, 35 mg weekly Multivitamin, over the counter B12 Tylenol, as needed for pain OBJECTIVE General: Maryanne is a 78‐year‐old female who is pleasant, slightly confused, and moderately anxious. Her daughter is present during the visit. The patient defers to her daughter for clarifica-tion of events and details. Daughter and mother have a positive working relationship with evi-dence of support and caring. Vital signs: T: 98. 2°F; P: 86; RR: 28; Sa O 2: 93; B/P: 140/70. Her weight is 191 pounds, and her height is 64 inches. Skin: Clear, slightly grayish color. HEENT: Hair thinning, gray at roots, silky texture. Sclera nonicteric, pupils dilated since she just came from the retinologist (examination of her eyes deferred). Oral mucosa, pink moist intact. Neck: Supple, no JVD, no bruits. Thyroid nonpalpable. No lymphadenopathy. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Fatigue, Confusion, and Weight Loss 215 Cardiovascular: Heart regular rate and rhythm. PMI is at 5th intercostal space left sternal border; + systolic murmur II/VI. Pulses positive all extremities. There is bilateral lower leg edema; chronic lymphedema; no ulcerations; skin intact; no hair growth; no pitting. Respiratory: Lungs clear to auscultation. Transverse/AP diameter 2/1. Abdomen: BS+, obese, soft, nontender. No hepatomegaly; no splenomegaly; no hernia. Neurological: CN I-XII grossly intact. Mental status 30/30 (Folstein Mini Mental Status Exam). Geriatric depression screen: No evidence of depression. Musculoskeletal: Walks with a cane; s/p right knee replacement 9 years ago. Full range of motion; no deformities; muscle strength appropriate for age. CRITICAL THINKING Which diagnostic studies should be considered to assist with or confirm the diagnosis?___CBC___FBS___CMP___Hb A1c___TSH___Ultrasound___Urea breath test___Iron studies What is the most likely differential diagnosis and why? ___Chronic kidney disease___Anemia (type?)___COPD___Obstructive sleep apnea___Dementia___Depression___Gastric ulcer What is the plan of treatment?What is the plan for referrals and follow‐up care?Are there standardized guidelines that should be used to assess or treat this case? NOTE: The author would like to acknowledge Geraldine F. Marrocco, Ed D, APRN, CNS, ANP‐BC for her contribution to this case in the first edition of this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
217 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Timothy is a right‐hand dominant, 45‐year‐old Caucasian male. He presents with a complaint of intermittent “right‐hand numbness. ” He first noticed the numbness about 8 months ago, but it was so slight that he thought nothing of it. Some mornings he wakes up with tingling in his right arm. He then shakes his hand, and the tingling goes away. He now complains of sharp, shooting pains going up his right arm over the past month; and last week, he dropped his hammer a few times while working. He denies any redness, swelling, weakness, or recent trauma to his right hand. He denies symptoms in his left hand. Past medical history: He dislocated his right shoulder playing basketball in high school. He occa-sionally has lower back pain and knee pain from all the sports he did in high school. He denies history of arthritis or fractures to the hands, arms, or neck. Family history: His mother is 67 years old and has a history of hypothyroidism and osteoarthritis. She was diagnosed with hypothyroidism at age 45 and is being treated with levothyroxine on a daily basis. His father is 70 years old and had a stroke at age 50. After extensive rehabilitation, his father exhibits few deficits. His sister is 48 years old and obese with diabetes mellitus Type 2. Timothy denies a family history of rheumatoid arthritis, osteoarthritis, gout, or carpal tunnel syndrome. Social history: Timothy is a carpenter by trade. He owns a furniture repair business. He is right‐ hand dominant. He is married to a schoolteacher and lives in a house that he built in the country. He states he makes a decent living and is very concerned with his right hand, as this will impact his livelihood. He has smoked about 1/2 to 1 pack of cigarettes per day for the past 15 years. He has tried to quit many times but has been unsuccessful. He drinks about a six‐pack of beer on the weekends. Medications: He takes ibuprofen, 200 mg, 2-3 tablets, every few days for knee and back pain. Otherwise, he denies use of any prescription, supplemental, or herbal medications. Allergies: He reports he gets a nonitchy rash when he takes amoxicillin. He can take penicillin without any problems. He denies any known allergies to food, latex, or the environment. Case 8. 13 Hand Numbness By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Subsets and Splits