Case Study: 84-Year-Old Patient

A 68 year old male presented to the emergency department at 0800 hours via ambulance after experiencing chest discomfort and intermittent palpitations since 0500 hours. Prior to presentation, the patient stated he

The care and management of patients suffering with a long term condition is an integral part of the nurse’s role. With approximately 15 million people in the UK suffering from at least one chronic illness (DoH, 2012), it becomes apparent why the Department of Health (DoH) and the National Health Service (NHS) have had to put in to place advice and guidelines in order that the appropriate measures are taken to ensure that these patients are cared for in the most productive way. This essay is going to discuss the issues that are associated with long term conditions and chronic illness. The focus of this discussion is going to be a case study on a patient who is currently

Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.

You are working in the internal medicine clinic of a large teaching hospital. Today your first patient is 70-year-old J.M, a man who has been coming to the clinic for several years for management of CAD and HTN. A cardiac catheterization done a year ago showed 50% stenosis of the circumflex coronary artery. He has had episodes of dizziness for the past 6 months and orthostatic hypotension, shoulder discomfort, and decreased exercise tolerance for the past 2 months. On his last clinic visit 3 weeks ago, a CXR showed cardiomegaly and a 12-lead ECG showed sinus tachycardia with left bundle branch block. You review his morning blood work and initial assessment.

The patient is a 76-year-old Hispanic gentleman brought to the ED by his wife because the patient has been anxious for 2 weeks and now unable to sleep much of the night. He denies any chest pain but has had on-and-off palpitations that seemed not to be related to activity or a particular time of day. He denies any shortness of breath, lightheadedness or loss of consciousness. He had two episodes of syncope three years ago. He was diagnosed with having an MI. He was at that time treated at St. Mary's Hospital in Passaic and underwent cardiac catheterization and he has had some stenting done to his coronary arteries. He saw his PMD approximately a week ago who prescribed some sleeping medicine and neurology consult which the patient has

“The patient is Adam Rudd, a 78 y/o white male with a history of hypertension. He has been diagnosed with hypertension past 15 years and is on anti-hypertensive medications and aspirin. He is very weak and short of breath. He is accompanied with his longtime friend Jennifer, who reports that Rudd was looking very weak and was complaining of severe headache and blurred vision before coming to the hospital. He is 5’9” and weighs 270 lb. Vital signs recorded were: oral temperature 98.20 F, BP 224/120 mm Hg with a heart rate of 102 beats/minute and respiration of 24 breaths per minute. The pulse oximetry reading was 94% on room air. He is complaining of severe headache and blurred vision. Rudd said that he did not take his antihypertensive medication or aspirin since he ran out of pills. He has not been taking his medication for past 15 days. He reports no known allergies to any medications or other substances.”

On Tuesday August 30, 2016 a Male 63 years of age came into Christus Spohn South Heath Center with a diagnostic order for chest and rib x-rays. He was being seen because of chest pain on his right side due to a fall. He had an extensive patient history of x-rays that went as far back as 2014. For the year of 2016 he received approximately 12 different x-ray series. For example, on January 12, 2016 he received a chest 1 view image and cardiac catheterization. On May 21, 2016 he received a chest 1 view and a complete 4 view foot. On May 30, 2016 he received a cardiac catheterization. On June 1, 2016 and again on June 2, 2016 he received a chest 1 view. On June 10, 2016 he received a catheterization. On August 25, 2016 he received a chest 2 view. On August 26, 2006 an upper extremity without contrast. The patient also has a history of open heart surgery and receives dialysis treatments and is on oxygen.

A elderly patient by the name of Mr. Nathan was hospitalized for Prostatic surgery. He woke up in the middle of the night and tried to leave. A registered nurse approached him and tried to hold him down. He pushed her into a wall and hit her in the face. As a result, she developed an concussion. There after, the unit clerk that was on duty called for security. Mr. Nathan tried escaping by running to the exit, but he was stopped by two orderlies and a security guard. During this time, Mr. Nathan was making accusations of false imprisonment. A doctor ordered restraining for him to be checked in an hour and ordered the patient to be sedated. Mr. Nathan was bruised in the struggle. In addition, the registered nurse was taken to the emergency room and couldn't go back to work for two weeks. Mr. Nathan said he will be suing the hospital for assault and false imprisonment.

The patient is a 74-year-old female who was brought to the emergency room by BLS when she awakened from sleep with severe shortness of breath. In transit she received sublingual Nitroglycerin note to supplementation as well as a nebulizer. When seen in the ED she was placed on BiPAP and nebulizer for approximately an hour. It is to be noted the patient has severe COPD and pulmonary hypertension. She does have coronary disease as well. It is to be noted that she is on Citrucel for her pulmonary hypertension. There are no blood gases done, however on BiPAP her O2 sats were 99%. Chest x-ray shows soft tissue mass I believe in the right upper lobe. I believe that this patient in view of her significant history of comorbidities and severe

History of Present Illness: Mr. Perkins is a very pleasant 50-year-old man who was referred for ongoing dyspnea on exertion. He states that his symptoms began about a year ago and at that time, he had extensive cardiac evaluation, which reveals significant mitral valve regurgitation for which he has mitral valve repair. Since that time, however, he states that his level of cardiovascular fitness has not returned to his previous baseline. He is here today for formal evaluation. It should be noted that he did have a right heart catheterization performed that showed normal LV function with normal right heart pressures in September 2014. It should also be noted that he was not anemic at that time. He also has exercise stress testing performed perioperatively, which demonstrated limited exercise treadmill test secondary to marked accelerated hypertensive blood pressure in response to exercise. He states that he normally works out on a regular basis. He has been working out actively for a while doing cross fit and doing plank holds and other strenuous activities. He also has membership to Planet Fitness where he does run on the treadmill, as well. He once again states that his cardiovascular endurance is not quite where he feels it should be. He denies any associated wheeze with his symptoms. He has no chest pain. He does note a chronic morning bout of productive sputum that has persisted for one year as well. He denies this as being a

A: Janie is a 60 year old Female with PMH of A-Fib, COPD, Hypothyroidism, HTN, Lung Cancer and recently diagnosed Pulmonary Embolism. Janie presents to ER for evaluation on SOB, cough with greenish sputum, sore thoart, hoarseness and generalized weakness. Janie lives at home with her husband, use to smoke ½ pack per week, but quit many years ago, denies alcohol or drugs. Family history is non-contributory. Allergies: NKDA. Differential diagnosis includes worsening Lung Ca, PE, COPD and CHF. Janie uses home O2 at 4 L/NC. V/S: T=98.7, HR=89, R=16, B/P=132/56, O2 sats=100% on 4L/NC, Pain=6/10. Labs: WBC=7.6, H&H=8.5/27, Na=141, Troponin=0.08/0.06, BNP=495, INR=4.2, UA=3+ protein, 1+ blood and 6-10 RBC. CXR: Impression:1). COPD with nonspecific coarsening of the basilar interstitium. 2). Mild cardiomegaly with borderline cardiac compensation. 3). Right

Case 1: a 57-year-old female patient presented with a pinkish small nodule 3 x 3 mm in diameter on right palatal area near teeth 14. Overall clinical examination revealed benign epithelial lesion with the similar nodule in the right index finger of the patient. The final diagnosis was papilloma. High intensity diode laser (810 nm, 3 w and 1.5 w) was used to ablate lesion and stop bleeding. Post irradiated area was healed normally and no recurrence was observed.

Patient is a 45 yo male; 5’7”, 221 lbs who entered the emergency room at 6:30 am on 9/7/14 with severe chest pain (onset at 6:00 am) radiating to his arm, L arm numbness and nausea and vomiting. Past medical history reported by wife includes peptic ulcer, tobacco use (1-2ppd for 27 years), elevated blood pressure (controlled by lopressor). Wife did not know of any family history but reports patient’s father is deceased, died at 42 in his sleep. Mother alive and with high blood pressure.

A 50-years-old man presents to the emergency department, in a rural area’s district hospital, with a history of central crushing chest pain radiating to the jaw, dyspnea and cold sweating for 4 hours. He has no significant past medical or recent surgical history. He has a blood pressure of 150/90 mmHg and a heart rate of 64 beats/min. His EKG at the time of admission is shown below:

The patient is a 69-year-old gentleman who presented to the ED on 9/11 complaining of abdominal pain, constipation and rectal pain. Initial referral was EHR it was determine the patient should be observation Dr. Aqel did not agree with that assessment and therefore this is a second review. As stated he presented with constipation, abdominal pain and specifically anal pain with no bowel movement for approximately 3 days prior to presentation. His medical history is significant for coronary artery disease having had bypass grafting in 2009, hypertension, hypercholesterolemia, diabetes mellitus, previous CVA, also known to have a atrial flutter. He therefore was admitted to the telemetry unit because of the flutter. The patient underwent