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NU610 Unit 6 Case Studies

UNIT 6 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS, ROS, RELEVANT HISOTRY, AND OBJECTIVE DATA INTO TYPHON FOR THREE FAMILY MEMBERS/FRIENDS

Case 1 – S.H

CHIEF COMPLAINT:

“I HAVE NO CURRENT CONCERNS; ROUTINE CHECK IN FOR BLOOD PRESSURE AND MEDICATION”

HISTORY OF PRESENT ILLNESS:

 (O)nset HYPERTENSION STARTED AT AGE 52  (L)ocation N/A  (D)uration N/A  (C)haracter N/A  (A)lleviating/Aggravating factors N/A  (R)aditation N/A  (T)ime N/A

Patient is a 61 year old female that presents today with no complaints. She is routinely seen to monitor her blood pressure and check blood pressure medications. She was diagnosed with hypertension at age 52, 9 years ago.

PAST MEDICAL HISTORY:

 Hypertension  Mild heart attack  Mild arthritis in bilateral hand  History of anxiety and depression  Bronchitis  Kidney stones

 Seasonal allergies

CURRENT MEDICATIONS:

 Metoprolol  Ibuprofen

FAMILY HISTORY:

 Mother: hypertension, stroke at age 65, skin cancer removed from shoulder

 Father: pasted away of Lou Gehrig’s disease at age 62  Maternal Grandmother: Unknown to patient  Maternal Grandfather: Unknown to patient  Paternal Grandmother: Died of old age  Paternal Grandfather: Heart disease, died of complications from heart disease

SOCIAL HISTORY:

 mother of 2  full-time job as accountant  Does not smoke cigarettes  Does not use illicit drugs  Drinks socially with friends once or twice a month

HEALTH PROMOTION:

 Patient due for Cholesterol, Hepatitis C, HIV/AIDS screening  Due for colonoscopy to screen for Colon Cancer  Immunizations are up to date  Patient had Pap and mammogram done last year

General- Denies any weight changes recently. Appears well groomed. No reports of weakness, fatigue, or fever.

Skin- Denies rashes, lumps, sores, itching, dryness, or changes to color of skin. No changes to moles or nails. Hair is starting to turn gray.

HEENT- No report of headaches, dizziness, or light headedness. Patient wears glasses. Denies, pain redness, spots, flashing lights, tearing, glaucoma or cataracts. Denies issues with hearing, tinnitus, earaches, vertigo, or infection. Does not suffer from frequent colds, nasal stuffiness, itching, nosebleeds, or sinus trouble. Reports no problems with teeth or gums, dentures, or dry mouth. Denies frequent sore throats or hoarseness.

Neck- Denies any swollen glands, lumps, pain or stiffness in neck.

Breasts- Denies, lumps, pain, or discharge from breasts. Performs self-exam once a month.

Respiratory- Denies shortness of breath, cough, wheezing or pain. Patient states that she tends to get bronchitis easily in the winter is she develops a cold.

Cardiovascular- Patient reports high blood pressure. States that a couple years ago she was under a lot of stress and reported having mild heart attack and has not had symptoms since. Denies chest pain or discomfort, murmurs, palpitations, shortness of breath, and swelling of extremities.

Gastrointestinal- Denies trouble swallowing, heartburn, nausea, or vomiting. No changes in appetite or bowel habits.

Peripheral vascular- Denies leg pain, cramps, clots, swelling or changes to color in extremities.

Urinary- Denies changes to urgency or frequency of urination. No recent blood or infection present. Patient has been treated for kidney stones in the past. Reports no incontinence.

Genital- Patient has completed two pregnancy and is menopausal

Musculoskeletal- Patient reports mild arthritis in hands. Denies all other joint pain, stiffness, gout, or backaches. Denies swelling, redness, pain, weakness, tenderness, or limitation to range of motion.

Psychiatric- Denies nervousness, mood, memory changes, suicidal ideations. Patient suffered depression when her father died and spoke with counselor at the time. Currently does not feel depressed.

Neurologic- Denies changes to mood, attention span, orientation, or speech. Reports no changes to memory or judgement. No headaches, dizziness, vertigo, or fainting.

Hematologic- Denies easily bruising or bleeding.

Endocrine- Denies excessive sweating, thirst or hunger. Reports no history of thyroid problems.

PHYSICAL EXAM:

General- Patient appears well groomed and dressed appropriately. Walks with normal gait and motor function. Patient is alert and orientated. Normal mood and affect.

Vital Signs- Blood pressure: 124/88, HR: 87, Resp: 16.

Skin- Appropriate moisture and temperature. Multiple freckles on face, arms. and legs. No apparent lesions. Inspection of hair is of normal texture and distribution. Nails are of normal color with no deformities. Patient is starting to grow grey hair. Nothing to note from palpation of scalp. Good turgor. No rashes or bruising.

 Head – Normocephalic, no visual or palpable masses. Face and skull symmetrical.  Eyes – Eyes are in alignment. Conjunctiva clear. Sclera appears white. Pupils are

equal, round, and reactive bilaterally. Extraocular movements intact bilaterally. Patient wears glasses.

 Ears – Inspection of ear within normal limits. No problems with hearing bilaterally. (Do not have proper equipment to complete exam)

 Nose – Inspection of nasal mucosa, septum and turbinate within normal limits, no lesions or inflammation. No tenderness with palpation of maxillary and frontal sinuses.

 Throat – Inspection of oral mucosa, gums, teeth, tongue, palate, tonsils, lips, and pharynx within normal limits (pink, equal, aligned)

Neck- Inspection and palpation of cervical lymph nodes note no masses. No deviation in the trachea. No enlargement of thyroid noted.

Respiratory- Inspection and palpation symmetrical with no masses or abnormalities noted. Clear to auscultation and percussion.

Cardiovascular- Regular rate and rhythm, no murmurs, or gallops.

Gastrointestinal- Bowel sounds heard in all four quadrants. No tenderness with palpation. No mases or hernias noted.

Peripheral vascular- No edema some varicose veins noted on outer left thigh. Peripheral pulses intact.

Musculoskeletal- Normal gait. No tenderness, crepitation, masses, instability or decrease range of motion. Inspection is symmetrical. No atrophy or abnormal strength or tone.

Neurologic- Cranial nerves 2-12 intact/normal. Sensation to pain and touch is normal. Reflexes intact.

Case 2 – M.B

“I HAVE NO CURRENT CONCERNS”

 (O)nset N/A  (L)ocation N/A

 (D)uration N/A  (C)haracter N/A  (A)lleviating/Aggravating factors N/A  (R)aditation N/A  (T)ime N/A

Patient is a 33 year old male that presents today with no complaints. Appears to be in good health.

 History of L4-L5 microdiscectomy

 No known allergies

 Ibuprofen on occasion

 Mother: healthy  Father: open heart surgery at age 67  Maternal Grandmother: Died of old age  Maternal Grandfather: Died of cancer (type unknown)  Paternal Grandmother: Died of old age  Paternal Grandfather: Died in motor vehicle accident

 Married, Father of 2  full-time job as financial manager  Does not smoke cigarettes  Does not use illicit drugs  Drinks one to two beers nightly  Exercises by playing basketball three times weekly

 Patient is due for blood pressure check  Denies need for HIV/AIDS screening as he has one sexual partner  Up to date on immunizations as he relies on health care provider records

Skin- Denies rashes, lumps, sores, itching, dryness, or changes to color of skin. No changes to moles or nails. Hair is starting to turn gray in beard.

HEENT- No report of headaches, dizziness, or light headedness. Denies, pain redness, spots, flashing lights, tearing, glaucoma or cataracts. Denies issues with hearing, tinnitus, earaches, vertigo, or infection. Does not suffer from frequent colds, nasal stuffiness, itching, nosebleeds, or sinus trouble. Reports no problems with teeth or gums, dentures, or dry mouth. Denies frequent sore throats or hoarseness.

Neck- Denies any swollen glands, lumps, pain, or stiffness in neck.

Breasts- N/A

Respiratory- Denies shortness of breath, cough, wheezing or pain.

Cardiovascular- Denies chest pain or discomfort, murmurs, palpitations, shortness of breath, and swelling of extremities.

Urinary- Denies changes to urgency or frequency of urination. No recent blood or infection present. Reports no incontinence.

Genital- Reports no hernias, lumps, sores, pain, or discharge. Denies concern for STIs.

Musculoskeletal- Denies all other joint pain, stiffness, gout, or backaches. Denies swelling, redness, pain, weakness, tenderness, or limitation to range of motion. Reports preventative stretching daily for past lower back injury.

Psychiatric- Denies nervousness, mood, memory changes, suicidal ideations.

Endocrine- Denies excessive sweating, thirst, or hunger. Reports no history of thyroid problems.

Vital Signs- Blood pressure: 118/68, HR: 70, Resp: 14.

Skin- Appropriate moisture and temperature. Patient has one lesion on back that is enlarged. Inspection of hair is of normal texture and distribution. Nails are of normal color with no deformities. Nothing to note from palpation of scalp. Good turgor. No rashes or bruising.

equal, round, and reactive bilaterally. Extraocular movements intact bilaterally.  Ears – Inspection of ear within normal limits. No problems with hearing

bilaterally. (Do not have proper equipment to complete exam)  Nose – Inspection of nasal mucosa, septum and turbinate within normal limits,

no lesions or inflammation. No tenderness with palpation of maxillary and frontal sinuses.

Case 3 – S.T

“I CURRENTLY HAVE NO CONCERNS”

 (O)nset N/A  (L)ocation N/A  (D)uration N/A  (C)haracter N/A  (A)lleviating/Aggravating factors N/A  (R)aditation N/A  (T)ime N/A

Patient is a 30 year old female that presents today with no complaints. Appears in relatively good heath and shape.

 History of kidney infections  Wisdom teeth out at age 17  History of starched corona  Vitiligo

 Tree Nuts

 Ibuprofen – rarely  Marana

 Mother: hypertension, kidney stones, history of depression  Father: open heart surgery in 2009 and 2020, pre-diabetic  Maternal Grandmother: stroke at 65, skin cancer on shoulder-surgically removed

 Maternal Grandfather: pasted away of Lou Gehrig’s disease at age 62  Paternal Grandmother: Heart disease, died of heart related complications  Paternal Grandfather: Heart disease, hypertension, died of heart attack

 full-time job as manager of operations  Does not smoke cigarettes  Does not use illicit drugs  Drinks socially with friends once a week  Runs daily for exercise  Married  No children

 Patient is due for blood pressure check  Denies need for HIV/AIDS screening as she has one sexual partner  Up to date on immunizations  Had Pap smear earlier this year

Skin- Denies rashes, lumps, sores, itching, dryness. Changes to color of skin as it gets lighter. No changes to moles or nails. Reports no changes with hair.

Urinary- Denies changes to urgency or frequency of urination. No recent blood or infection present. Patient has been treated for kidney stones in the past. Reports no incontinence. Has not had a kidney infection for ten plus years.

Genital- Patient Denies concern for STIs. Does not get period with Marana.

Musculoskeletal- Denies all other joint pain, stiffness, gout, or backaches. Denies swelling, redness, pain, weakness, tenderness, or limitation to range of motion.

Vital Signs- Blood pressure: 120/76, HR: 78, Resp: 16.

Skin- Appropriate moisture and temperature. No apparent lesions. Inspection of hair is of normal texture and distribution. Nails are of normal color with no deformities. Nothing to note from palpation of scalp. Good turgor. No rashes or bruising.

equal, round, and reactive bilaterally. Extraocular movements intact bilaterally. Patient has contacts placed.

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KLouque Unit 6 Assignment Neuro Case Study

Advanced pathophysiology (nu 621), herzing university.

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Unit 6 Assignment: Traumatic Brain Injury

Kacie Louque Herzing University NU621-7E: Advanced Pathophysiology Markiesha Edgerton, DNP, APRN, AGPCNP-BC, WHNP-BC June 20, 2021

Traumatic Brain Injury Traumatic brain injuries are one of the leading causes of death worldwide and affect all ages and ethnicities. Brain injuries result in an alteration or death of brain structure and function. Primary brain injuries can arise from various etiologies, such as motor vehicle accidents, falls, or trauma. Secondary injuries are a systemic response from the body's current conditions, such as cerebral vascular accidents from hypertension (McCance & Huether.)

The identification and treatment of the primary traumatic brain injury are imperative to patient survival. Therefore, early identification by computed tomography and treatment by neurosurgical intervention are one of healthcare's main goals to preserve as much brain function as possible (Sedden & Fisher, 2021). In this paper, different types of brain injury will be discussed, and the treatment recommended to optimize patient outcomes.

Pathophysiology

An extradural hematoma, or subdural hematoma, is an accumulation of blood between the dura matter and the skull. An arterial bleed is the source for 85% of cases, with a venous bleed accounting for 15% (McCance & Huether, 2019). Extradural hematomas are most often caused by motor vehicle damage with injury to the temporal fossa. Rapid bleeding from an injury to the middle meningeal vein or artery causes the temporal lobe to shift medially from increased intracranial pressure (Lafta et al., 2020). Signs and symptoms include severe headache, vomiting, confusion, seizure, drowsiness, ipsilateral pupil dilation, loss of consciousness, and hemiparesis (McCance & Huether, 2019). The patient may show signs from minutes to hours after injury. Patients that exhibit signs of increased intracranial pressure require emergency evacuation of the hematoma.

Head Injury

The first injury the patient experienced is coup which is the initial impact of the skull to the windshield. Due to the severity of the accident, the patient also experienced contrecoup (McCance & Huether, 2019). Contrecoup is the rebound effect of the brain hitting the back of the skull. Both of these mechanisms cause contusions to the brain. Although it is unknown which part of the patient's skull struck the windshield, it is likely the patient may have suffered either an epidural hematoma or an acute subdural hematoma from coup and contrecoup. Therefore, emergency intervention is crucial for survival and further deterioration of brain function.

In the treatment of traumatic brain injury, guidelines are considered paramount in patient management (Khormi et al., 2018). Upon arrival to the emergency room, a Glasgow coma score should be performed. The patient should be placed in a cervical collar for spinal immobilization while preparing for endotracheal intubation. The patient should be sent for a computer tomography to determine the type of traumatic brain injury that occurred. Since his head trauma is severe, he is likely experiencing increased intracranial pressure. The patient should be sent for emergency surgical evacuation of the hematoma to prevent herniation from the pressure. Once stabilized, the patient should be admitted to a neuro intensive care unit to manage the intracranial pressure and additional deficits, if any.

While in the ICU, steps should be taken to treat increased intracranial pressure, such as elevating the head of bed 30-45 degrees, administration of mannitol, administration of anti- seizure medications, analgesic medications, and sedatives (Chestnut et al., 2020). Cerebral perfusion pressure must remain greater than 70 mmgHg and intracranial pressure must be less than 20 mmHg (McCance & Huether, 2019). Blood pressure, heart rate, and body temperature

must also be maintained per physician parameters. Neurological assessments should be performed frequently as directed by the physician. When the patient returns to consciousness, he will need to be seen by physical and occupation therapy with the goal of performing activities of daily living independently. A consultation with psychiatry should be included in the treatment plan if any deficits occurred. Anxiety and or depression may be evaluated at this time. The patient is to be educated on the importance of compliance with neurology appointments to assess and treat any lasting deficits or late signs of injury.

Conclusion Traumatic brain injuries will continue to be one of the main types of trauma around the world. The exact type of brain injury will depend on the location and velocity of the impacting mechanism. Epidural hematomas and subdural hematomas are two common examples of head trauma frequently seen in emergency settings. Therefore, it is the duty of the healthcare professional to recognize the early signs of brain injury and provide competent early interventions to prevent further deterioration of health.

• Multiple Choice

Course : Advanced Pathophysiology (NU 621)

University : herzing university.

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