NURS6531 Advanced Practice Care of Adults Across the Life Span

Week 2 Forum

Diagnosing Integumentary Disorders

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

Case Study 1

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

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

Case Study 2

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

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

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

Case Study 3

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

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

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

To prepare:

Review Part 5 of the Buttaro et al. text and the case studies provided

You will either select or be assigned one of the three case studies provided.

Reflect on the provided patient information including history and physical exams.

Think about a differential diagnosis. Consider the role the patient history and physical exam played in your diagnosis.

Reflect on potential treatment options based on your diagnosis.

Note: For this Forum, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Forum Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

By Day 3

Post an explanation of the primary diagnosis, as well as 3 differential diagnoses, for the patient in the case study that you selected or were assigned. Describe the role the patient history and physical exam played in the diagnosis. Then, suggest potential treatment options based on your patient diagnosis.

NURS6531 Advanced Practice Care of Adults Across the Life Span

Week 3 Forum

Diagnosing HEENT Disorders

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

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

Case Study 1

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

Case Study 2

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

Face: Faint asymmetry with left periauricular area slightly edematous

Eyes: sclera clear, conj wnl

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

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

+ tenderness L preauricular node, otherwise no lymphadenopathy

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

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

Case Study 3

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

To prepare:

Review the case studies provided in this week’s Resources.

You will either select or be assigned one of the three case studies provided.

Reflect on the provided patient information including history and physical exams.

Think about a differential diagnosis. Consider the role the patient history and physical exam played in your diagnosis.

Reflect on potential treatment options based on your diagnosis.

NURS6531 Advanced Practice Care of Adults Across the Life Span

Week 5 Forum

Examining Chest X-Rays

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

Consider the three patient case studies and x-rays

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

Case Study 1

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

SH: works as a law clerk

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

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

Case Study 2

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

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

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

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

PE: VS: Ht: 5’7, Wt: 150#, BMI 23,

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

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

Case Study 3

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

MEDS: Glyburide 10mg qd

PE: She looks ill with continuous coughing and chills.

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

Lungs: +Crackles, increased fremitus

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

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

To prepare:

Review Part 10 of the Buttaro et al. text in this week’s Resources, as well as the provided x-rays.

Reflect on what you see in the x-ray assigned to you by the Course Instructor. https://aptitudenursingpapers.com/