Chamberlain College of Nursing - NR 507Week 3 Case Study NR507: And Discussion Part 2 and Part 3. Grade A.

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Discussion Part One (graded) INITIAL HISTORY: Tom is a 47 year old male who presents with gradual onset of dyspnea on exertion and fatigue. He also complains of frequent dyspepsia with nausea and o... ccasional epigastric pain. So far you only know that he has a history of alcohol abuse. Discussion question part one: What questions would you like to ask this patient about his symptoms? Reference Platt, A., & Eckman, J. R. (2009). Diagnosing Anemia. Clinician Reviews, 16(12), 43-51. Discussion Part Two (graded) ADDITIONAL HISTORY: He says he has not had his usual energy levels for months; dyspnea has become much worse in the last few weeks which is why he came in. Tom denies chest pain, orthopnea, edema, cough, wheezing, or recent infections. He states he has occasional episodes of hematemesis after drinking heavily, and subsequently has had several days of dark stools. Tom consumes up to 2 six-packs of beer a day for the past 8 years since losing his job. Nothing seems to make his breathing any better, but antacids help with is epigastric discomfort and dyspepsia. PAST MEDICAL HISTORY: Denies history of cardiac or pulmonary disease Diagnosed with duodenal ulcer in the past and was on “3 drugs at once” for a while 2 years ago, but stopped taking them due to the expense His only surgical history was a childhood tonsillectomy De does not smoke or take any medications except for over the counter antacids He has no known allergies PHYSICAL EXAMINATION: Thin and pale white male looking older than his stated age with no acute distress T = 37 C orally; P = 95 and regular; RR = 16 and unlabored; B/P = 128/72 sitting Skin, HEENT, Neck: Skin pale without rash, no spider angiomata Sclera pale with no icterus PERRLA, fundi without lesions Pharynx is clear without postnasal drainage NO thyromegaly, adenopathy, or bruits Lungs, Cardiac: Good lung expansion, lungs clear to auscultation and percussion PMI at 5th intercostal space at midclavicular line Heart rhythm regular with a grade II/VI systolic ejection murmur at left sternal border No gallops, heaves, or thrills Abdomen, Rectal: Abdomen nondistended; bowel sounds present Liver 8 cm. At midclavicular line Moderate epigastric tenderness without rebound or guarding Prostate not enlarged and nontender Stool guaiac positive Extremities, Neurological: No joint deformity, muscle tenderness or edema Alert and oriented X 3 Strength is 5/5 throughout and sensation intact Gait normal. DTR 2 + and symmetrical throughout Discussion questions part two: What are the pertinent positives and negatives on examination related to his presenting problem? What is your differential diagnosis at this time? What laboratory studies should be obtained at this time? Reference Platt, A., & Eckman, J. R. (2009). Diagnosing Anemia. Clinician Reviews, 16(12), 43-51. Discussion Part Three (graded) LABORATORY RESULTS: WBC = normal with a normal differential and platelet count Hct = 29%; MCV = normal, MCHC = slightly decreased; RDW = markedly increased; reticulocyte count < 2% Smear with mixed microcytic/hypochromic and macrocytic/normochromic red blood cells; WBC and platelets appear normal PT/PTT, liver function tests, electrolytes, and amylase normal Upper endoscopy with 2 cm. duodenal ulcer with evidence of recent but no acute hemorrhage ADDITIONAL LABORATORY RESULTS: Serum iron, total iron binding capacity, saturation, and ferritin all reduced Bone marrow biopsy with megaloblastic changes and low iron stores Ø Serum folate and red blood cell folate low; B12 normal Discussion questions part three: Based on these findings, what are the diagnoses for this patient? How should this patient be managed? References Ho, K., Kuan, A., Zaño, F., Goh, K., Mahachai, V., Kim, D., & Yoon, H. (2009). Randomized, parallel, double-blind comparison of the ulcer-healing effects of ilaprazole and omeprazole in the treatment of gastric and duodenal ulcers. Journal of Gastroenterology, 44(7), 697-707. Rx List. (2015). Prevacid. Retrieved from http://www.rxlist.com/prevacid-drug.htm. University of Michigan. (2009). Guidelines for clinical care. Peptic ulcer disease. Retrieved from www.med.umich.edu/1info/fhp/practiceguides/newpud/pud.pdf. Reference Kalra, L., Hamlyn, A., & Jones, B. (2009). Blue sclera: A common sign of iron deficiency? Lancet, 2(8518), 1267-1269. [Show More]

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