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NR 601 Week 1 Case Study Discussions (Part 1)
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Discussion Part One (graded)
You meet your first patient of the morning. A.K. is a 65-year-old
Caucasian male who you are seeing for the first time. Both wife and
daughter are present.
Background
He reports that he has had an 18-pound unintentional weight loss in the
last 2 months “I am just not hungry anymore, and when I do eat, I get
full so fast. In fact, it is really hard to eat, and I don’t eat nearly as much
as usual, even though I eat 3 times every day”. He also reports feeling
more tired than usual. “I am not sleeping very well. My wife wakes me
up when I am snoring, or when she thinks I am not breathing. I used to
have sleep apnea, but I don’t think I have it anymore. Besides, that mask
is so horrible to wear.” He reports day time somnolence. He reports that
he is at the clinic today because of his wife and daughter’s concern about
his weight loss and loss of appetite.

PMH
Mr. A.K. has a history of hypertension, cataracts, and osteoarthritis.
Current medications:
Ibuprofen 600 mg po TID
Lisinopril 20 mg po QD
Hydrochlorothiazide 25 mg PO QD
Simvastatin 20 mg po QD
Vitamin D3 50,000 units po weekly
Omeprazole 40 mg po QD
Sudafed 50 mg po TID prn
Surgeries

April 2010-Right cataract extraction with Intraocular Lens Placement
June 2010- Left cataract extraction with Intraocular Lens Placement
November 2011-Left total knee arthroplasty
Allergies: No known drug or food allergies. Allergies to latex causing
difficulty breathing and to bee stings, causing widespread edema and
airway obstruction.
Vaccination History
He receives annual flu shots “most of the time”. His last one was 18
months ago.
Received a Pneumovax “the day I turned 65”.
His last TD was greater than 10 years ago.
Has not had the herpes zoster vaccine.
Social history

He has an 8th grade education and is a retired concrete finisher. He lives
with his wife of 45 years and his daughter lives next door. He enjoys
working in his back yard garden and recently tripped over the garden
hose last week where his neighbor had to come and help him up.
Family history
Both parents are deceased. Father died of a heart attack at the age of 80;
mother died of breast cancer at the age of 76. He has one daughter who
is 45 years old and has hypertension. Hypertension, coronary artery
disease, and cancer runs in the family.
Habits
He drinks one 4 ounce glass of red wine nightly; previous smoker of 30
years; he quit for 10 years, and is now smoking ¼ pack per day for the
last 6 months.
Discussion Part One:
Provide the differential diagnoses (DD) with rationale
===============================================
NR 601 Week 1 Case Study Discussions (Part 2)

Discussion Part Two (graded)
Physical examination
Vital Signs:
Height: 5 feet 7 inches Weight: 170 pounds Waist Circumference – 32
inches BP 130/84 T 98.0 po P 92 regular R 22, non-labored
HEENT: normocephalic, symmetric. Evidence of prior cataract surgery
in both eyes. PERRLA, EOMI, cerumen impaction bilateral ears.
Several broken teeth, loose partial plate.
NECK: Neck supple; non-palpable lymph nodes; no carotid bruits.

LUNGS: Decreased breath sounds bases bilaterally, clear to auscultation
HEART: RRR with regular without S3, S4, murmurs or rubs.
ABDOMEN: Bloated appearance, active bowel sounds, LLQ tenderness
and 6 cm x 7 cm mass.
PV: Pulses are 2+ BL in upper and lower extremities; no edema
NEUROLOGIC: Negative
GENITOURINARY: no CVA tenderness
MUSCULOSKELETAL: gait fluid and steady. No muscle atrophy or
asymmetry. Full ROM all joints. Strength 5/5 and equal bilaterally.
Hips: Discomfort on flexion in both hips; extensor and flexor strength
symmetrical.
Knees: Left knee discomfort with weight bearing. No redness, warmth
or edema. Full ROM in both knees with symmetrical extensor and flexor
strength. Crepitus on extension of left knee.
Hands: No redness or swelling. Bilateral joint tenderness of the distal
interphalangeal and proximal interphalangeal joints of the 2nd and 3rd
digits.

Calf circumference-31 cm; Mid-arm circumference- 22 cm
PSYCH: normal affect
SKIN: Pale. Areas of healing ecchymosis: Left knee- 3 cm x 2 cm x 0
cm. Right knee -2 cm x 2.5 cm x 0 cm.
Discussion Part Two:
Summarize the history and results of the physical exam. Discuss the
differential diagnosis and rationale for choosing the primary diagnosis.
Include one evidence-based journal article that supports your rationale
and include a complete treatment plan that includes medications,
possible referrals, patient education, ICD 10 Codes, and plan for follow-
up.
===============================================
NR 601 Week 2 Case Study Discussions(Part-1)

B.J., a 70-year-old Caucasian female has been seen in the clinic several
times over the last 3 years. However, she missed her last annual
appointment-last appointment was 18 months ago and today you are the
nurse practitioner seeing her. She arrived to the clinic alone and states
she is “here for my check-up”.
Background:
The patient reports that “my feet just burn and tingle all the time and it is
so much worse at night that I can hardly sleep at all”. She also indicates
that “I need some new pillows; I use 3 of them now to just get
comfortable at night to sleep. Those pillows help me catch my breath so
I can sleep better”. She also reports dyspnea just walking to the
bathroom, but it only happens when her legs are “swole up” and also
states, “the coughing also keeps me up at night”. To be honest, “I’m just
tired in general whether my feet are “swole” or not”. She also indicates
that she cannot see well, especially at night. She also reported that at her

last visit to the clinic, she was told that she had a “heart beat problem”
and that she is supposed to be taking aspirin every day. She said she
thinks all of her “heart pains” went away after she started taking the
aspirin and “putting that pill under the tongue”. One of her concerns she
has today is that since her husband died last year, she tells you, “I just
don’t like doing things that I liked to do before my husband died. We
used to like to do all sorts of stuff, but anymore….I just feel blue all the
time”.
PMH:
Chronic back pain
Hypertension
Previous history of MI in 2010
Diabetes?
Hypothyroidism?
Constipation?

Congestive Heart Failure?
Coreg 6.25 mg PO BID
Colace 100 mg PO BID
Glucotrol XL 10 mg PO daily
Lantus insulin 20 units at HS
K-dur 20 mEq PO QD
Furosemide 40 mg PO QD
L-Thyroxine 112 mcg PO QD
Aspirin?
Nitroglycerine?

Surgeries:
2010-Left Anterior Descending (LAD) cardiac stent placement
Allergies: Amoxicillin
Vaccination History:
She receives an annual flu shot. Last flu shot was this year
Has never had a Pneumovax
Has not had a Td in over 20 years
Has not had the herpes zoster vaccine
Other:
Has not seen a dentist in over 15 years, the time she got her dentures
Last colorectal screening was 11 years ago

Last mammogram was 5 years ago
Has never had a DEXA/Bone Density Test
Last dilated eye exam was 4 years ago
Labs from last year’s visit: Hgb 12.2, Hct 37%, Hgb A1C 8.2%, K+ 4.2,
Na+140,Cholesterol 186, Triglycerides 188, HDL 37, LDL 98, TSH 3.7,
ALT/AST WNL.
Social history:
She graduated from high school, and thought about college, but got
married right away and then had kids a short time later. Her two sons
and their wives live with her, take her to church and to the local senior
center; they do all the cleaning, run errands, and do grocery shopping.
Family history:
Both parents are deceased. Father died of a heart attack; mother died of
natural causes. She had one brother who died of a heart attack 20 years
ago at the age of 52.

Habits:
Patient is a current tobacco user and has smoked 1 pack of cigarettes
daily for the last 50 years and reports having no desire to quit. She uses
occasional chew. She drinks one 4 ounce glass of red wine daily.
Provide differential diagnoses (DD) with rationale.
Further ROS questions needed to develop DD.
Based on the patient data provided, choose geriatric assessment tools
that would be appropriate to use in conducting a thorough geriatric
assessment. Provide a rationale on why you are choosing these particular
tools.
===============================================

Physical examination:
Vital Signs
Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8 BP 110/70 T
98.0 po P 100 R 22, non-labored; Urinalysis: Protein 2+, Glucose: 4+
HEENT: normocephalic, symmetric. Bilateral cataracts; PERRLA,
EOMI; Upper and lower dentures in place a fitting well. No tinnitus
Thyroid non-palpable
LUNGS: Decreased breath sounds in bases bilaterally with rales,
expiratory wheezing with prolonged expiratory phase noted throughout
all lung fields. No costovertebral angle tenderness (CVAT) noted.
Increase in AP diameter noted.
HEART: Irregularly irregular rhythm; Unable to detect S3 or murmur

ABDOMEN: Normal contour; active bowel sounds all four quadrants;
no palpable masses.
PV: Pulses are 2+ in upper extremities and 1+ in pedal pulses
bilaterally. 2+ pitting edema to her knees noted bilaterally;
NEUROLOGIC: Achilles reflexes are hypoactive bilaterally. Vibratory
perception to the 128 Hz tuning fork placed at the MTP of her great toe
is absent bilaterally; She is unable to discern monofilament placement in
3 locations on her left foot and 2 places on her right foot.
GENITOURINARY: no CVA tenderness; not examined
MUSCULOSKELETAL: Heberden’s nodes at the DIP joints of all
fingers and crepitus of the bilateral knees on flexion and extension with
tenderness to palpation medially at both knees. Kyphosis and gait slow,
but steady.
PSYCH: normal affect; her Mini-Cog Score is 3. Her PHQ-9 score is
22.
SKIN: Sparse hair noted on lower legs and feet bilaterally with dry skin
on her ankles and feet.
possible referrals, patient education, ICD 10 Codes, and plan for follow
up.

===============================================
Katie Smith, a 65 year-old female of Irish descent, is being seen in your
office for an annual physical exam. You are concerned since she has
rescheduled her appointment three times after forgetting about it. She
and her husband John are currently living with their daughter Mary, son-
in-law Patrick, and their four children. She confesses that while she
loves her family and appreciates her daughter’s hospitality, she misses
having her own home. As she is telling you this, you notice that she
develops tears in her eyes and does not make eye contact with you.
Background:

Although Mrs. Smith is scheduled for an annual physical exam and
reports no particular chief complaint, you will need to complete a
detailed geriatric assessment. Katie reports a lack of appetite. She tells
you that she nibbles most of the time rather than eating full meals. She
also reports having insomnia on a regular basis.
PMH:
Katie reports a recent bout of pneumonia approximately 3 months ago,
but did not require hospitalization. She also has a history of HTN and
high cholesterol.
HCTZ 25mg daily
Evista 60mg daily
Multivitamin daily
Surgeries:

Appendectomy as a child in Ireland (date unknown)
1968- Cesarean section
Allergies: Denies food, drug, or environmental allergies
Cannot remember when she had her last influenza vaccine
Does not recall having received a Pneumovax
Her last TD was greater than 10 years ago
Screening History:
Last Colonoscopy was 12 years ago

Last mammogram was 4 years ago
Has never had a DEXA/Bone Density Test
Social history:
Emigrated with her husband from Ireland in her 20s and has always
lived in the same house until recently. She retired a year and a half ago
from 30 years of teaching elementary school; has never smoked but
drinks alcohol socially. She states that she does not have an advanced
directive, but her daughter Mary keeps asking her about setting one up.
Family history:
Both parents are deceased but lived disease-free up into their late 90s.
She has one daughter who is 44 years old with no chronic illness and
two sons, ages 42 and 40, both in good health.
Discussion Day 1:
Differential Diagnoses with rationale

Further ROS questions needed to develop DD
tools.
===============================================

Vital Signs:
Height: 5’0” Weight: 150 pounds BMI: 29.3 BP: 120/64 T: 98.0
oral P: 68 regular R: 16, non-labored
HEENT: Normocephalic, symmetric. Evidence of prior cataract surgery
in both eyes. PERRLA, EOMI, cerumen impaction bilateral ears.
LUNGS: Clear to auscultation
ABDOMEN: Normal contour; active bowel sounds, LLQ tenderness.
PV: Pulses are 2+ BL in upper and lower extremities; no edema. No

evidence of peripheral neuropathy.
GENITOURINARY: No CVA tenderness
MUSCULOSKELETAL: Gait fluid and steady. No muscle atrophy or
asymmetry. Full ROM all joints. Strength 5/5 and equal bilaterally. Joint
swelling in fingers both hands.
PSYCH: Flat affect; patient declined to answer PHQ-9 and GDS
SKIN: Grossly intact without rashes or ecchymosis.

up.
===============================================
You are seeing S.F., a 74-year-old. Hispanic male in the office this
morning for difficulty breathing.
Background:

S.F. presents with increased dyspnea on exertion that has become
progressively worse over the last 3 days. You observe that he is using
pursed lip breathing as he explains his chief complaint. He reports that
he has been coughing up a moderate amount of thick, green sputum for
approximately one week that was accompanied by a fever of 100.6 and
chills. He took Ibuprofen 400 mg every 4 hours and increased his fluid
intake for the last week. Two days ago he noticed that the sputum is now
yellow rather than green and that he has not experienced any more fever.
Overall, he feels like he is getting better. However, the dyspnea on
exertion developed three days ago without relief despite the use of his
Spiriva HandiHaler. He reports that he lost his rescue inhaler and has not
had it to use in over 2 months.
PMH:
COPD
Hypertension
Osteoarthritis

Asprin-81 daily
Cyclobenzaprine 10 mg prn
Meloxicam 15 mg daily
Metoprolol 25 mg daily
Spiriva HandiHaler daily as directed
Tramadol 50 mg daily prn
Surgeries:
Appendectomy as a child (date unknown)
2004-Left cataract extraction with intraocular lens placement
2008-Right cataract extraction with intraocular lens placement
Allergies: NKA

Influenza vaccine- October 2013
Pneumovax-2010
His last TD-can’t remember
Has not a TDAP/TD in 20 years
Screening History:
Last Colonoscopy was 2012-normal
Last dilated retinal and glaucoma exam was 2013
Social history:
Retired roofer-stopped working in 2004 due to arthritis and pain in his
rotator cuff. Is married and lives with spouse. They have 4 grown

children who live within a 10 mile radius of them. Currently smokes-is
down to ½ pack cigarettes daily. Has smoked for 45 years total.
Family history:
Father is deceased and had a history of hypertension and diabetes;
Mother is deceased and had a history of CAD/MI; Sister-history of colon
cancer.
Provide differential diagnoses (DD)with rationale.
tools.
===============================================

Vital Signs:
Height: 5’8” Weight: 188 pounds BMI: 28.58 BP: 130/70 T: 99.0
oral P: 72 regular R: 24, pursed-lip breathing; Pain level-7-right
shoulder
HEENT: Normocephalic, symmetric. PERRLA, EOMI, cerumen
impaction bilateral ears.

LUNGS: Labored respirations; posterior RLL, LLL, RML, LML
diminished breath sounds. Rhonchi right and left anterior chest.
ABDOMEN: Normal contour; active bowel sounds, LLQ tenderness.
PV: Diminished pedal pulses; hair loss noted over extremities.
GENITOURINARY: Urinary dribbling, urgency, gets up 4 times during
the night, distended bladder.
MUSCULOSKELETAL: Limited ROM in right shoulder. Crepitus in
knees bilaterally.
PSYCH: Negative

SKIN: Negative
up.
===============================================
NR 601 Week 5 Case Study Discussions (Part-1)

C.W. is a tall, thin 78-year-old African American male brought into the
office by his son who states that the patient is restless, angry, and has
been unable to sleep for the last week. The son indicates that he is very
concerned about his father because he lives alone. Also, he is concerned
about the “strange” symptoms that his father has presented with recently.
Background:
C.W. presents as restless, hyperverbal, obnoxious and angry. He
expresses himself by periodic yelling. He is unkempt and smells strongly
of urine, alcohol and body odor. ………… has an unsteady gait and
sways while standing. As you converse with the son, you determine that
C.W. was medically separated from military service due to mental health
issues after 2 years of active duty that ended in 1947. He has been
married and divorced three times over the years. He typically seeks no
acute or preventative medical care. ___ was treated by a psychiatrist

previously, but he did not like taking the prescribed medications so he
stopped taking them and did not keep any further psychiatric
appointments.
PMH:
Patient denies any previous diagnoses. However, when asked why he
saw a psychiatrist in the past, he tells you that the psychiatrist diagnosed
paranoid schizophrenia, but that he does not have any psychiatric
diagnoses or problems. He states: “It was just a way for him to make
money off me coming in and seeing him and paying the drug companies
for me to take all those meds!”
Denies prescription medications, over the counter medication, herbal
therapies or vitamins.
Surgeries:

Denies surgeries
Allergies: NKA
Flu vaccine: never given
Pneumovax: never given
Tetanus: never given
Herpes zoster: never given
Screening History:

Last Colonoscopy was 2012-normal
Last dilated retinal and glaucoma exam was 2013
Social history and Risk Factors:
Patient admits to smoking cigarettes and cigars. …… estimates that he
smokes about 1 pack of cigarettes daily for the last 40 years, and 2 cigars
each week for the last 30 years.
He states that he drinks a 24 ounce bottle of beer 4-6 times a week. …
denies drinking wine or hard liquor. …….. does admit to smoking
marijuana on occasion but does not use other recreational drugs.
Patient denies falling. You notice some scrapes on his forearms, and
when asked, he tells you that he fell yesterday: “I got pretty drunk out
fishin’ with friends and fell off my bike trying to ride home”. He does
not use any assistive devices for ambulation or balance.
Significant ROS:

Productive cough with white sputum. Denies hemoptysis.
He answers “No” to the PHQ-2 screening questions.
Family history:
Reports no significant family history
tools.

===============================================
NR 601 Week 5 Case Study Discussions (Part-2)
Vital Signs:
Height: 5’8” Weight: 154 pounds BMI: 23.4 BP: 132/76 P: 76
regular R: 16

HEENT: Normocephalic, symmetric. PERRLA, EOMI, no cataracts
noted; poor dentition.
LUNGS: Respirations are unlabored, decreased breath sounds and
crackles at the bases bilaterally. Prolonged expiratory phase throughout
lung fields, inspiratory wheezes and a productive cough of cloudy white
sputum.
ABDOMEN: Round, firm abdomen; active bowel sounds; non-tender.
NEUROLOGIC: Unsteady gait, swaying while standing during periods
of agitation. Achilles reflexes are present bilaterally. Strength is equal
but decreased in the upper and lower extremities bilaterally.
GENITOURINARY: Urinary incontinence with strong odor of urine.
NO CVA tenderness.
MUSCULOSKELETAL: Mild kyphosis. Heberden’s nodes at the distal
interphalangeal joints (DIP) of all fingers, and marked crepitus of the
bilateral knees on flexion and extension. Pedal pulses palpable. No
edema noted in lower extremities.

PSYCH: Manic, restless, angry and hyperverbal
SKIN: Right forearm with 3 cm x 5 cm x 0 cm dry, scabbed abrasion.
Left forearm with 4 cm x 5 cm x 0 cm dry, scabbed abrasion.
===============================================
NR 601 Week 6 Case Study Discussions Health
Promotion, Health Protection, Disease Prevention, and
Treatment Considerations in Long-Term Care (Part-1)

Ms. S. is a 62-year-old black female who has returned to the clinic to
discuss her concerns that her lifestyle modifications to lose weight have
not worked. At the last visit 3 months ago, she was advised to change
her eating habits and increase activity to promote weight loss. She
reports walking at least 30 minutes a day but has lost very little weight.
……….. indicates that the walking only made her extremely thirsty and
hungry and attributes her increased thirst and hunger to increased
exercise and her increased urination due to drinking more water since
“it’s been hot lately” and exercise makes me thirsty”…… has returned to
the clinic to discuss if there is anything else that can be done to lose
weight and to determine why she is so tired, thirsty and hungry all the
time. She also thinks she may have an overactive bladder since she has
to urinate frequently during the day, which has influenced her not to go
on outings with her friends.
Discussion Questions Part One
Conduct a ROS on this patient.
Indicate which symptoms are most concerning to you.
List your differential diagnoses.
What types of screenings would be appropriate to use based on the chief
complaint?

What primary diagnosis are you choosing at this point?
===============================================
NR 601 Week 6 Case Study Discussions Health
Treatment Considerations in Long-Term Care (Part-2)
Physical Exam:

Vital signs: blood pressure 145/90, heart rate 100, respirations 20
height 5’1”; weight 210 pounds
Labwork:
CBC: normal
UA: 2+ glucose; 1+ protein; negative for ketones
CMP: BUN/Creat. elevated; Glucose is 300 mg/dL
Hemoglobin A1c: 12%
Thyroid panel: normal
LFTs: normal
Cholesterol: total cholesterol (206), LDL elevated; HDL is low
EKG: normal
General: obese female in not acute distress

HEENT: unremarkable
CV: S1 and S2 RRR without murmurs or rubs
Lungs: Clear to auscultation
Abdomen– soft, round, nontender with positive bowel sounds present;
no organomegaly; no abdominal bruits
Discussion Questions Part Two
For the primary diagnosis, what non-pharmacological and
pharmacological strategies would be appropriate?
Include the following: lab work and screenings to be completed.
Describe patient education strategies.
Describe follow-up and any referrals that may be necessary.

===============================================
NR 601 Week 7 Case Study Discussion Health
Treatment Considerations in End-Of-Life Care (Part-1)
C.G. is a 69-year-old male with a history of right head and neck cancer
that you have been following for one year. The carcinoma was initially
localized to the head and neck-specifically at the left lingual tonsil
region and went on to complete a total of 6 weeks of radiation and
chemotherapy. Recently, the last PET scan indicated some metabolic
activity in the left lymph node area along with other regions of abnormal
metabolic activity in the body-particularly the liver and the lungs
indicating metastasis. C.G. indicates that he is tired of the effects of
chemotherapy and radiation and does not want to pursue any more
treatment for cancer.

Background:
Right head and neck cancer with metastasis to liver and lungs; patient is
refusing further treatment.
PMH:
Hypertension
Hyperlipidemia
Stomatitis
Anemia
Neutropenia

Carvedilol 12.5 mg po 1 daily
Furosemide 40 mg po daily
Surgeries:
2012: right radical neck dissection
Allergies:
None
Influenza vaccine last received 1 year ago
Received pneumovax at age 65
Received Tdap 5 years ago

Social history and Risk Factors:
Former smoker-stopped smoking at the time his cancer was diagnosed-2
years ago
Negative for alcohol intake or drug use
Patient does not have an advanced directive or living will. He is refusing
further treatment for his cancer and his wife and children are in
disagreement with him. The patient wants to know what his options are
for the remainder of his life.
Family history:
Negative

Identify the legal/ethical issues involved with the patient and describe
your approach to addressing end-of-life care for this patient.
===============================================
NR 601 Week 7 Case Study Discussion Health
Treatment Considerations in End-Of-Life Care (Part-2)

Vital Signs: Height: 6’0 Weight: 140 pounds; BMI: 19.0 BP: 156/84
P: 84 regular R: 20
HEENT: normocephalic, symmetric PERRLA, EOMI; poor dentition
NECK: left neck supple; non-palpable lymph nodes; no carotid bruits.
Limited ROM
LUNGS: rhonchi in anterior chest bilaterally.
HEART: S1 and S2 audible; regular rate and rhythm
ABDOMEN: active bowel sounds all 4 quadrants; Normal contour;
RUQ tenderness; liver palpable
NEUROLOGIC: negative
GENITOURINARY: negative

MUSCULOSKELETAL: negative
PSYCH: PHQ-9 is 15
SKIN: oral mucosa irritated-stomatitis
up.
===============================================

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