NURS 612 Shadow Health All Modules Cases Instructor Keys CASE STUDY

Module 1 - Health History Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. Timeframe: 1 week after fall (Age: 28) Reason for visit: Patient presents for an initial primary care visit today complaining of an infected foot wound. Learning Objectives Develop strong communication skills ⦁ Interview the patient to elicit subjective health information about her health and health history ⦁ Ask relevant follow-up questions to evaluate patient condition ⦁ Demonstrate empathy for patient perspectives, feelings, and sociocultural background ⦁ Identify opportunities to educate the patient Document accurately and appropriately ⦁ Document subjective data using professional terminology ⦁ Organize appropriate documentation in the EHR Demonstrate clinical reasoning skills ⦁ Organize all components of an interview ⦁ Assess risk for disease, infection, injury, and complications After completing the assessment, you will reflect on personal strengths, limitations, beliefs, prejudices, and values. Module Features ⦁ Information Processing Activity ⦁ Student Performance Index - This style of rubric contains subjective and objective data categories. Subjective data categories include interview questions and patient data. Objective data categories include examination and patient data. ⦁ Acute pain of the foot ⦁ Local infection of skin and subcutaneous tissue of the foot ⦁ Uncontrolled type 2 diabetes mellitus ⦁ Acanthosis nigricans ⦁ Asthma ⦁ Dysmenorrhea ⦁ Hirsutism ⦁ Hypertension ⦁ Menorrhagia ⦁ Obesity ⦁ Oligomenorrhea ⦁ Polycystic ovarian syndrome History of Present Illness One week after sustaining the cut, Tina Jones develops an infection in the cut on the bottom of her foot; she seeks treatment when the infection starts to swell and produce pus. Day 1 (Onset): Tina was at home, going down the back steps, and she tripped. She turned her ankle and scraped the bottom of her foot. The wound bled, but she stopped the bleeding quickly and cleaned the wound. She worried that she had sprained her ankle, and her mom drove her to the ER. (“a week ago”) The ER did an xray (no broken bones), gave her a prescription for Tramadol, and sent her home. In the following days, her ankle seemed fine not as serious as she thought. Day 2 - 4: She cleaned the wound dutifully, twice a day, with soap and water or hydrogen peroxide, let it dry, put Neosporin on it, and bandaged it. The wound wasn’t getting worse, but it wasn’t healing, either. She expresses that she “took really good care of it.” Tina was able to go to work and attend school. Day 4: Tina went to her cousin’s house, where she encountered cats and experienced wheezing. She tried two puffs on her albuterol inhaler, and she had to do a third puff. (“three days ago”) Day 5 - 6: Tina noticed pus in the wound, and swelling, redness and a warm feeling in her foot. Her pain increased to the point she was unable to walk. She began to take the Tramadol to try to manage the pain, but it didn’t resolve the pain completely. She missed class and work. (“two days ago”) On the night of Day 6: Tina started to run a fever. They took her temperature at home, and it was 102. (“last night”) Morning of Day 7: Tina finally recognizes that her foot infection is not going to get better, and her mom takes her to the nurse practitioner to get the foot looked at. Subjective and Objective Model Documentation Printable “Answer Key” available within the Shadow Health DCE. Chief Complaint ⦁ Symptoms - Foot pain and discharge ⦁ Diagnosis - Infected foot wound Vitals ⦁ Weight (kg) - 88 ⦁ BMI - 30.5 ⦁ Heart Rate (HR) - 82 ⦁ Respiratory Rate (RR) - 16 Medications ⦁ Acetaminophen 500-1000 mg PO prn (headaches) ⦁ Ibuprofen 600 mg PO TID prn (menstrual cramps) ⦁ Tramadol 50 mg PO BID prn (foot pain) Allergies ⦁ Penicillin: rash ⦁ Denies food and latex allergies ⦁ Allergic to cats and dust. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. ⦁ Pulse Oximetry - 99% ⦁ Blood Pressure (BP) - 139/87 ⦁ Blood Glucose - 117 ⦁ Temperature (F) - 98.9 ⦁ Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: “a few months ago”) Abnormal Findings Reported during Chief Complaint interview ⦁ Reports open foot wound and throbbing pain ⦁ Rates present pain at a 7 out of 10 ⦁ Discharge, redness, swelling, and warmth around foot wound ⦁ Reports a fever last night and presents with a fever of 101.1 F ⦁ Pain affects ability to walk, job performance, and class attendance Assessment Right foot wound with evidence of infection Plan Reported during Past Medical History interview ⦁ Diagnosed with asthma in childhood and uses an inhaler 2 to 3 times per week ⦁ Allergic to penicillin, dust and cats, which cause wheezing ⦁ Diagnosed with Type 2 diabetes ⦁ Does not currently take medication for diabetes and does not monitor blood glucose ⦁ Heavy menstrual flow, heavy cramping, and irregular periods ⦁ Occasional headaches and eye strain ⦁ Increased thirst and more frequent urination ⦁ Recent 10lb unintentional weight loss ⦁ Habitual diet soda drinking ⦁ Clean wound with normal saline and redress with clean gauze. ⦁ Educate patient on when to seek emergent care, signs and symptoms of infection, and daily wound care. ⦁ Return to clinic one week to re-evaluate wound and assess need for antibiotics. Module 2 - HEENT For the last week, Tina has experienced sore, itchy throat, itchy eyes, and runny nose. She states that these symptoms started spontaneously and have been constant in nature. She has treated her throat pain with occasional throat lozenges which has “helped a little”. She states that her nose “runs all day” and has clear discharge. She denies cough and recent illness. She denies fevers, chills, and night sweats. Timeframe: 1 month after establishing primary care (Age: 28) Reason for visit: Patient presents complaining of nose and throat symptoms. Learning Objectives Develop strong communication skills ⦁ Interview the patient to elicit subjective health information about her health and health history ⦁ Ask relevant follow-up questions to evaluate patient condition ⦁ Demonstrate empathy for patient perspectives, feelings, and sociocultural background ⦁ Identify opportunities to educate the patient Document accurately and appropriately ⦁ Document subjective data using professional terminology ⦁ Organize appropriate documentation in the EHR Demonstrate clinical reasoning skills ⦁ Organize all components of an interview ⦁ Assess risk for disease, infection, injury, and complications After completing the assessment, you will reflect on personal strengths, limitations, beliefs, prejudices, and values. Module Features ⦁ Student Performance Index - This style of rubric contains subjective and objective data categories. Subjective data categories include interview questions and patient data. Objective data categories include examination and patient data. History of Present Illness Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of sore, itchy throat, itchy eyes, and runny nose for the last week. She states that these symptoms started spontaneously and have been constant in nature. She does not note any specific aggravating symptoms, but states that her throat pain seems to be worse in the morning. She rates her throat pain as 4/10. She has treated her throat pain with occasional throat lozenges which has “helped a little”. She states that she has some soreness when swallowing, but otherwise no other associated symptoms. She states that her nose “runs all day” and is clear discharge. She has not attempted any treatment for her nasal symptoms. She states that her eyes are constantly itchy and she has not attempted any eye specific treatment. She denies cough and recent illness. She has had no exposures to sick individuals. She denies changes in her hearing, vision, and taste. She denies fevers, chills, and night sweats. She has never been diagnosed with seasonal allergies, but does note that her sister has “hay fever”. Subjective and Objective Model Documentation Printable “Answer Key” available within the Shadow Health DCE. Vitals ⦁ Weight (kg) - 89 ⦁ BMI - 30.8 ⦁ Heart Rate (HR) - 80 ⦁ Respiratory Rate (RR) - 16 Medications ⦁ Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing: “when around cats,” last use in the past week) Review of Systems ⦁ Pulse Oximetry - 99% ⦁ Blood Pressure (BP) - 141/82 ⦁ Blood Glucose - 199 ⦁ Temperature (F) - 99.1 ⦁ Acetaminophen mg PO prn (headaches ⦁ Ibuprofen 600 mg PO TID prn (cramps) ⦁ General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. ⦁ Head: Denies history of trauma. Denies current headache. ⦁ Eyes: She does not wear corrective lenses, but notes that her vision has been worsening over the past few years. She complains of blurry vision after reading for extended periods. Denies increased tearing or itching prior to this past week. ⦁ Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. ⦁ Nose/Sinuses: Denies rhinorrhea prior to this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. ⦁ Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph nodes, or wounds in mouth. No sore throat prior to this episode. ⦁ Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16 for asthma, last chest XR was age 16. Her current inhaler use has been her baseline of 2-3 times per week. Chief Complaint ⦁ Symptoms - Sore and itchy throat, runny nose, itchy eyes ⦁ Diagnosis - Allergic rhinitis Abnormal Findings Subjective (Reported by Tina) ⦁ Reports sore and itchy throat for the past week ⦁ Associated symptoms are red, itchy eyes and runny nose ⦁ Reports unrelated occasional headaches and eye strain Assessment Allergic Rhinitis Plan  Objective (Found by the student performing physical exam) ⦁ Oropharynx slightly erythematous with mild cobblestoning ⦁ Injection visible on conjunctiva ⦁ Nasal mucosa pale and boggy ⦁ Observable intermittent cough ⦁ Left fundus with sharp disc margins, no hemorrhages; right fundus with mild ⦁ retinopathic changes ⦁ Visual acuity: 20/40 right eye, 20/20 left eye ⦁ Acanthosis nigricans noted on neck ⦁ Encourage Ms. Jones to continue to monitor symptoms and log her episodes of allergic symptoms with associated factors and bring log to next visit. ⦁ Initiate trial of loratadine (Claritin)10 mg by mouth daily. ⦁ Encourage to increase intake of water and other fluids and educate on frequent handwashing. ⦁ Educate on avoidance of triggers and known allergens ⦁ Educate Ms. Jones on when to seek care including episodes of uncontrollable epistaxis, worsening headache, or fever. ⦁ Revisit clinic in 2-4 weeks for follow up and evaluation. Module 3 - Respiratory Tina had an asthma episode 2 days ago. At that time she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Since that incident she notes that she has had 10 episodes of wheezing and has shortness of breath approximately every four hours. Tina presents with continued shortness of breath and wheezing. Timeframe: 3 months after establishing primary care (Age: 28) Reason for visit: Patient presents complaining of a recent asthma episode that is not fully resolved. Learning Objectives Develop strong communication skills ⦁ Interview the patient to elicit subjective health information about her health and health history ⦁ Ask relevant follow-up questions to evaluate patient condition ⦁ Demonstrate empathy for patient perspectives, feelings, and sociocultural background ⦁ Identify opportunities to educate the patient Document accurately and appropriately ⦁ Document subjective data using professional terminology ⦁ Organize appropriate documentation in the EHR Demonstrate clinical reasoning skills ⦁ Organize all components of an interview ⦁ Assess risk for disease, infection, injury, and complications After completing the assessment, you will reflect on personal strengths, limitations, beliefs, prejudices, and values. Module Features ⦁ Student Performance Index - This style of rubric contains subjective and objective data categories. Subjective data categories include interview questions and patient data. Objective data categories include examination and patient data. History of Present Illness Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of shortness of breath and wheezing following a near asthma attack that she had two days ago. She reports that she was at her cousin’s house and was exposed to cats which triggered her asthma symptoms. At the time of the incident she notes that her wheezes were a 6/10 severity and her shortness of breath was a 7-8/10 severity and lasted five minutes. She did not experience any chest pain or allergic symptoms. At that time she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Since that incident she notes that she has had 10 episodes of wheezing, and has a nonproductive cough and episodes of shortness of breath approximately every four hours. Her last episode of shortness of breath was this morning before coming to clinic. She notes that her current symptoms seem to be worsened by lying flat, activity, and are accompanied by a non-productive cough. She awakens with night-time shortness of breath twice per night. She complains that her current symptoms are beginning to interfere with her daily activities and she is concerned that her albuterol inhaler seems to be less effective than previous. Currently she states that her breathing is normal. Diagnosed with asthma at age 2.5 years. She has no recent use of spirometry, does not use a peak flow, does not record attacks, and does not have a home nebulizer or vaporizer. She has been hospitalized five times for asthma, last at age 16. She has never been intubated for her asthma. She does not have a current pulmonologist or allergist. Subjective and Objective Model Documentation Printable “Answer Key” available within the Shadow Health DCE. Vitals ⦁ Weight (kg) - 89 ⦁ BMI - 30.8 ⦁ Heart Rate (HR) - 89 ⦁ Respiratory Rate (RR) - 20 Medications ⦁ Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheez- ing: “when around cats,” last use this morning). She does admit to needed an occasional third puff for symptom relief. She reports that the inhaler does not seem to be as effective in treating her symptoms recently. Review of Systems ⦁ Pulse Oximetry - 97% ⦁ Blood Pressure (BP) - 140/81 ⦁ Blood Glucose - 224 ⦁ Temperature (F) - 98.5 ⦁ Acetaminophen 500-1000 mg PO prn (headaches) ⦁ Ibuprofen 600 mg PO TID prn (cramps) ⦁ General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. ⦁ Nose/Sinuses: Denies rhinorrhea with this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. ⦁ Gastrointestinal: No changes in appetite, no nausea, no vomiting, no symptoms of GERD or abdominal pain ⦁ Respiratory: Complains of shortness of breath and cough as above. Denies sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16. Chief Complaint ⦁ Symptoms - Shortness of breath, decreased inhaler effectiveness ⦁ Diagnosis - Asthma exacerbation Abnormal Findings Subjective (Reported by Tina) ⦁ Reports recent asthma exacerbation with wheezing and shortness of breath ⦁ Uses rescue inhaler more than prescribed and notices decreased inhaler effectiveness ⦁ Cats, dust, and some activity are asthma triggers Assessment Asthma exacerbation Plan  Objective (Found by the student performing physical exam) ⦁ Oxygen saturation 97% ⦁ FVC is 3.91 L and FEV1/FVC ratio is 80.56% ⦁ Wheeze and slight prolonged expiration upon auscultating lower posterior lungs ⦁ Ms. Jones was encouraged to continue to monitor symptoms and log her episodes of asthma symptoms and wheezing with associated factors and bring log to next visit. ⦁ Obtain office oxygen saturation. ⦁ Order PFTs to be completed after exacerbation to have baseline available for future comparison. ⦁ Encouraged to wash bedding and consider dust mite covers to decrease allergic nighttime symptoms. ⦁ NMT in office x 1. ⦁ Educated to increase intake of water and other fluids. ⦁ Educated Ms. Jones on when to seek emergent care including episodes of chest pain or shortness of breath unrelieved by rest, worsening asthma symptoms or wheezing, or the sense that rescue inhaler is not helping. ⦁ Revisit clinic in 24 weeks for follow up and evaluation. Introduction Daniel “Danny” Rivera is an 8-year-old boy who comes to the clinic with a cough. Students determine if Danny is in distress, explore the underlying cause of his cough, and look for related symptoms in other body systems. Case Highlights Ask about a variety of psychosocial factors related to home life, such as second-hand smoke exposure Observe non-verbal cues as Danny presents with intermittent coughing and visible breathing difficulty Rule out asthma, a common childhood affliction, by examining Danny Learning Objectives Perform a focused assessment of the respiratory system ⦁ Gather subjective and objective data ⦁ Select and use the appropriate tools and tests necessary for a focused exam ⦁ Consider and assess regional system involvement Differentiate between variations of normal and abnormal assessment findings to determine the cause and severity of the event. ⦁ Create a differential diagnosis Practice patient-centered care ⦁ Convey empathy with therapeutic communication ⦁ Provide patient education on condition, diagnosis, or treatment while respecting variance in health literacy ⦁ Express consideration and respect for patient perspectives, feelings, and sociocultural background Evaluate, and document patient assessment data using information systems technology Interview using communication techniques appropriate for a pediatric patient Promote patient safety, privacy, and infection control Communicate critical information effectively to another healthcare professional during the transfer of patient care. Reflect on personal strengths, limitations, beliefs, prejudices, and values Body Systems of Study ⦁ Primary: Respiratory ⦁ Secondary: HEENT, Cardiovascular Chief Complaint “I’ve been coughing a lot the past four. . . no I’ve been coughing for five days.” Abnormal Findings INTERVIEW ⦁ Reports wet cough for several days ⦁ Cough is worse at night ⦁ Reports frequent cough as part of medical history ⦁ Father smokes indoors ⦁ Frequent ear infections when he was younger ⦁ Frequent rhinorrhea ⦁ Had pneumonia last year ⦁ Starting to feel pain in his right ear EXAM ⦁ Rhinorrhea with clear mucus; inside nostril appearance red ⦁ Increased respiratory rate ⦁ Appears fatigued ⦁ Nasal discharge, boggy turbinate, and visible crease on nose from rubbing ⦁ Audible coarse crackles in upper airway; bronchovesicular on both sides, clears with cough ⦁ Mild tachycardia ⦁ Lymph nodes enlarged and tender on the right side ⦁ Right ear has erythematous; canal is clear and a little red. The tympanic membrane is red and inflamed ⦁ Fine bumps on tongue ⦁ Tenderness in throat; “cobble stoning” in back of throat **For instructor use** Focused Exam Case - G DRivera v1 || Copyright © 2014 ShadowH Module 4 - Cardiovascular Over the last month, Tina has experienced 3-4 episodes of perceived rapid heart rate. She describes these episodes as “thumping in her chest” with a heart rate that is “way faster than usual”. She does not associate the rapid heart rate with a specific event, but notes that they usually occur about once per week in the morning on her commute to class. The episodes generally last between 5 and 10 minutes and resolve spontaneously. She denies chest pain during the episodes. Timeframe: 4 months after establishing primary care (Age: 28) Reason for visit: Patient presents complaining of recent episodes of fast heartbeat. Learning Objectives Develop strong communication skills