NR 601 Effective Communication - tutorialrank.com

1. NR 601 Week 1 Case Study Discussions (Part 1) For more course tutorials visit www.tutorialrank.com Discussion Part One (graded) You meet your first patient of the morning. A.K. is a 65-year-old Caucasian male who you are seeing for the first time. Both wife and daughter are present. Background He reports that he has had an 18-pound unintentional weight loss in the last 2 months “I am just not hungry anymore, and when I do eat, I get full so fast. In fact, it is really hard to eat, and I don’t eat nearly as much as usual, even though I eat 3 times every day”. He also reports feeling more tired than usual. “I am not sleeping very well. My wife wakes me up when I am snoring, or when she thinks I am not breathing. I used to have sleep apnea, but I don’t think I have it anymore. Besides, that mask is so horrible to wear.” He reports day time somnolence. He reports that he is at the clinic today because of his wife and daughter’s concern about his weight loss and loss of appetite.

2. PMH Mr. A.K. has a history of hypertension, cataracts, and osteoarthritis. Current medications: Ibuprofen 600 mg po TID Lisinopril 20 mg po QD Hydrochlorothiazide 25 mg PO QD Simvastatin 20 mg po QD Vitamin D3 50,000 units po weekly Omeprazole 40 mg po QD Sudafed 50 mg po TID prn Surgeries

3. April 2010-Right cataract extraction with Intraocular Lens Placement June 2010- Left cataract extraction with Intraocular Lens Placement November 2011-Left total knee arthroplasty Allergies: No known drug or food allergies. Allergies to latex causing difficulty breathing and to bee stings, causing widespread edema and airway obstruction. Vaccination History He receives annual flu shots “most of the time”. His last one was 18 months ago. Received a Pneumovax “the day I turned 65”. His last TD was greater than 10 years ago. Has not had the herpes zoster vaccine. Social history

4. He has an 8th grade education and is a retired concrete finisher. He lives with his wife of 45 years and his daughter lives next door. He enjoys working in his back yard garden and recently tripped over the garden hose last week where his neighbor had to come and help him up. Family history Both parents are deceased. Father died of a heart attack at the age of 80; mother died of breast cancer at the age of 76. He has one daughter who is 45 years old and has hypertension. Hypertension, coronary artery disease, and cancer runs in the family. Habits He drinks one 4 ounce glass of red wine nightly; previous smoker of 30 years; he quit for 10 years, and is now smoking ¼ pack per day for the last 6 months. Discussion Part One: Provide the differential diagnoses (DD) with rationale *******************************************************8 NR 601 Week 1 Case Study Discussions (Part 2)

5. For more course tutorials visit www.tutorialrank.com Discussion Part Two (graded) Physical examination Vital Signs: Height: 5 feet 7 inches Weight: 170 pounds Waist Circumference – 32 inches BP 130/84 T 98.0 po P 92 regular R 22, non-labored HEENT: normocephalic, symmetric. Evidence of prior cataract surgery in both eyes. PERRLA, EOMI, cerumen impaction bilateral ears. Several broken teeth, loose partial plate. NECK: Neck supple; non-palpable lymph nodes; no carotid bruits.

6. LUNGS: Decreased breath sounds bases bilaterally, clear to auscultation HEART: RRR with regular without S3, S4, murmurs or rubs. ABDOMEN: Bloated appearance, active bowel sounds, LLQ tenderness and 6 cm x 7 cm mass. PV: Pulses are 2+ BL in upper and lower extremities; no edema NEUROLOGIC: Negative GENITOURINARY: no CVA tenderness MUSCULOSKELETAL: gait fluid and steady. No muscle atrophy or asymmetry. Full ROM all joints. Strength 5/5 and equal bilaterally. Hips: Discomfort on flexion in both hips; extensor and flexor strength symmetrical. Knees: Left knee discomfort with weight bearing. No redness, warmth or edema. Full ROM in both knees with symmetrical extensor and flexor strength. Crepitus on extension of left knee. Hands: No redness or swelling. Bilateral joint tenderness of the distal interphalangeal and proximal interphalangeal joints of the 2nd and 3rd digits.

7. Calf circumference-31 cm; Mid-arm circumference- 22 cm PSYCH: normal affect SKIN: Pale. Areas of healing ecchymosis: Left knee- 3 cm x 2 cm x 0 cm. Right knee -2 cm x 2.5 cm x 0 cm. Discussion Part Two: Summarize the history and results of the physical exam. Discuss the differential diagnosis and rationale for choosing the primary diagnosis. Include one evidence-based journal article that supports your rationale and include a complete treatment plan that includes medications, possible referrals, patient education, ICD 10 Codes, and plan for follow- up. *******************************************************8 NR 601 Week 2 Case Study Discussions(Part-1) For more course tutorials visit

8. www.tutorialrank.com Discussion Part One (graded) B.J., a 70-year-old Caucasian female has been seen in the clinic several times over the last 3 years. However, she missed her last annual appointment-last appointment was 18 months ago and today you are the nurse practitioner seeing her. She arrived to the clinic alone and states she is “here for my check-up”. Background: The patient reports that “my feet just burn and tingle all the time and it is so much worse at night that I can hardly sleep at all”. She also indicates that “I need some new pillows; I use 3 of them now to just get comfortable at night to sleep. Those pillows help me catch my breath so I can sleep better”. She also reports dyspnea just walking to the bathroom, but it only happens when her legs are “swole up” and also states, “the coughing also keeps me up at night”. To be honest, “I’m just tired in general whether my feet are “swole” or not”. She also indicates that she cannot see well, especially at night. She also reported that at her

9. last visit to the clinic, she was told that she had a “heart beat problem” and that she is supposed to be taking aspirin every day. She said she thinks all of her “heart pains” went away after she started taking the aspirin and “putting that pill under the tongue”. One of her concerns she has today is that since her husband died last year, she tells you, “I just don’t like doing things that I liked to do before my husband died. We used to like to do all sorts of stuff, but anymore….I just feel blue all the time”. PMH: Chronic back pain Hypertension Previous history of MI in 2010 Diabetes? Hypothyroidism? Constipation?

10. Congestive Heart Failure? Current medications: Coreg 6.25 mg PO BID Colace 100 mg PO BID Glucotrol XL 10 mg PO daily Lantus insulin 20 units at HS K-dur 20 mEq PO QD Furosemide 40 mg PO QD L-Thyroxine 112 mcg PO QD Aspirin? Nitroglycerine?

11. Surgeries: 2010-Left Anterior Descending (LAD) cardiac stent placement Allergies: Amoxicillin Vaccination History: She receives an annual flu shot. Last flu shot was this year Has never had a Pneumovax Has not had a Td in over 20 years Has not had the herpes zoster vaccine Other: Has not seen a dentist in over 15 years, the time she got her dentures Last colorectal screening was 11 years ago

12. Last mammogram was 5 years ago Has never had a DEXA/Bone Density Test Last dilated eye exam was 4 years ago Labs from last year’s visit: Hgb 12.2, Hct 37%, Hgb A1C 8.2%, K+ 4.2, Na+140,Cholesterol 186, Triglycerides 188, HDL 37, LDL 98, TSH 3.7, ALT/AST WNL. Social history: She graduated from high school, and thought about college, but got married right away and then had kids a short time later. Her two sons and their wives live with her, take her to church and to the local senior center; they do all the cleaning, run errands, and do grocery shopping. Family history: Both parents are deceased. Father died of a heart attack; mother died of natural causes. She had one brother who died of a heart attack 20 years ago at the age of 52.

13. Habits: Patient is a current tobacco user and has smoked 1 pack of cigarettes daily for the last 50 years and reports having no desire to quit. She uses occasional chew. She drinks one 4 ounce glass of red wine daily. Discussion Part One: Provide differential diagnoses (DD) with rationale. Further ROS questions needed to develop DD. Based on the patient data provided, choose geriatric assessment tools that would be appropriate to use in conducting a thorough geriatric assessment. Provide a rationale on why you are choosing these particular tools. *******************************************************8

14. NR 601 Week 2 Case Study Discussions(Part-2) For more course tutorials visit www.tutorialrank.com Discussion Part Two (graded) Physical examination: Vital Signs Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8 BP 110/70 T 98.0 po P 100 R 22, non-labored; Urinalysis: Protein 2+, Glucose: 4+ HEENT: normocephalic, symmetric. Bilateral cataracts; PERRLA, EOMI; Upper and lower dentures in place a fitting well. No tinnitus NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. Thyroid non-palpable LUNGS: Decreased breath sounds in bases bilaterally with rales, expiratory wheezing with prolonged expiratory phase noted throughout all lung fields. No costovertebral angle tenderness (CVAT) noted. Increase in AP diameter noted. HEART: Irregularly irregular rhythm; Unable to detect S3 or murmur

15. ABDOMEN: Normal contour; active bowel sounds all four quadrants; no palpable masses. PV: Pulses are 2+ in upper extremities and 1+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally; NEUROLOGIC: Achilles reflexes are hypoactive bilaterally. Vibratory perception to the 128 Hz tuning fork placed at the MTP of her great toe is absent bilaterally; She is unable to discern monofilament placement in 3 locations on her left foot and 2 places on her right foot. GENITOURINARY: no CVA tenderness; not examined MUSCULOSKELETAL: Heberden’s nodes at the DIP joints of all fingers and crepitus of the bilateral knees on flexion and extension with tenderness to palpation medially at both knees. Kyphosis and gait slow, but steady. PSYCH: normal affect; her Mini-Cog Score is 3. Her PHQ-9 score is 22. SKIN: Sparse hair noted on lower legs and feet bilaterally with dry skin on her ankles and feet. Discussion Part Two: Summarize the history and results of the physical exam. Discuss the differential diagnosis and rationale for choosing the primary diagnosis. Include one evidence-based journal article that supports your rationale and include a complete treatment plan that includes medications, possible referrals, patient education, ICD 10 Codes, and plan for follow up.

16. *******************************************************8 NR 601 Week 3 Case Study Discussions(Part-1) For more course tutorials visit www.tutorialrank.com Discussion Part One (graded) Katie Smith, a 65 year-old female of Irish descent, is being seen in your office for an annual physical exam. You are concerned since she has rescheduled her appointment three times after forgetting about it. She and her husband John are currently living with their daughter Mary, son- in-law Patrick, and their four children. She confesses that while she loves her family and appreciates her daughter’s hospitality, she misses having her own home. As she is telling you this, you notice that she develops tears in her eyes and does not make eye contact with you. Background:

17. Although Mrs. Smith is scheduled for an annual physical exam and reports no particular chief complaint, you will need to complete a detailed geriatric assessment. Katie reports a lack of appetite. She tells you that she nibbles most of the time rather than eating full meals. She also reports having insomnia on a regular basis. PMH: Katie reports a recent bout of pneumonia approximately 3 months ago, but did not require hospitalization. She also has a history of HTN and high cholesterol. Current medications: HCTZ 25mg daily Evista 60mg daily Multivitamin daily Surgeries: Appendectomy as a child in Ireland (date unknown)

18. 1968- Cesarean section Allergies: Denies food, drug, or environmental allergies Vaccination History: Cannot remember when she had her last influenza vaccine Does not recall having received a Pneumovax Her last TD was greater than 10 years ago Has not had the herpes zoster vaccine Screening History: Last Colonoscopy was 12 years ago Last mammogram was 4 years ago

19. Has never had a DEXA/Bone Density Test Social history: Emigrated with her husband from Ireland in her 20s and has always lived in the same house until recently. She retired a year and a half ago from 30 years of teaching elementary school; has never smoked but drinks alcohol socially. She states that she does not have an advanced directive, but her daughter Mary keeps asking her about setting one up. Family history: Both parents are deceased but lived disease-free up into their late 90s. She has one daughter who is 44 years old with no chronic illness and two sons, ages 42 and 40, both in good health. Discussion Day 1: Differential Diagnoses with rationale

20. Further ROS questions needed to develop DD Based on the patient data provided, choose geriatric assessment tools that would be appropriate to use in conducting a thorough geriatric assessment. Provide a rationale on why you are choosing these particular tools. *******************************************************8 NR 601 Week 3 Case Study Discussions(Part-2) For more course tutorials visit www.tutorialrank.com Discussion Part Two (graded) Physical examination:

21. Vital Signs: Height: 5’0” Weight: 150 pounds BMI: 29.3 BP: 120/64 oral P: 68 regular R: 16, non-labored T: 98.0 HEENT: Normocephalic, symmetric. Evidence of prior cataract surgery in both eyes. PERRLA, EOMI, cerumen impaction bilateral ears. NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. LUNGS: Clear to auscultation HEART: RRR with regular without S3, S4, murmurs or rubs. ABDOMEN: Normal contour; active bowel sounds, LLQ tenderness. PV: Pulses are 2+ BL in upper and lower extremities; no edema. No evidence of peripheral neuropathy.

22. NEUROLOGIC: Negative GENITOURINARY: No CVA tenderness MUSCULOSKELETAL: Gait fluid and steady. No muscle atrophy or asymmetry. Full ROM all joints. Strength 5/5 and equal bilaterally. Joint swelling in fingers both hands. PSYCH: Flat affect; patient declined to answer PHQ-9 and GDS SKIN: Grossly intact without rashes or ecchymosis. Discussion Part Two: Summarize the history and results of the physical exam. Discuss the differential diagnosis and rationale for choosing the primary diagnosis. Include one evidence-based journal article that supports your rationale

23. and include a complete treatment plan that includes medications, possible referrals, patient education, ICD 10 Codes, and plan for follow up. *******************************************************8 NR 601 Week 4 Case Study Discussions(Part-1) For more course tutorials visit www.tutorialrank.com Discussion Part One (graded) You are seeing S.F., a 74-year-old. Hispanic male in the office this morning for difficulty breathing. Background:

24. S.F. presents with increased dyspnea on exertion that has become progressively worse over the last 3 days. You observe that he is using pursed lip breathing as he explains his chief complaint. He reports that he has been coughing up a moderate amount of thick, green sputum for approximately one week that was accompanied by a fever of 100.6 and chills. He took Ibuprofen 400 mg every 4 hours and increased his fluid intake for the last week. Two days ago he noticed that the sputum is now yellow rather than green and that he has not experienced any more fever. Overall, he feels like he is getting better. However, the dyspnea on exertion developed three days ago without relief despite the use of his Spiriva HandiHaler. He reports that he lost his rescue inhaler and has not had it to use in over 2 months. PMH: COPD Hypertension Osteoarthritis Current medications: Asprin-81 daily

25. Cyclobenzaprine 10 mg prn Meloxicam 15 mg daily Metoprolol 25 mg daily Spiriva HandiHaler daily as directed Tramadol 50 mg daily prn Surgeries: Appendectomy as a child (date unknown) 2004-Left cataract extraction with intraocular lens placement 2008-Right cataract extraction with intraocular lens placement Allergies: NKA

26. Vaccination History: Influenza vaccine- October 2013 Pneumovax-2010 His last TD-can’t remember Has not a TDAP/TD in 20 years Screening History: Last Colonoscopy was 2012-normal Last dilated retinal and glaucoma exam was 2013 Social history: Retired roofer-stopped working in 2004 due to arthritis and pain in his rotator cuff. Is married and lives with spouse. They have 4 grown children who live within a 10 mile radius of them. Currently smokes-is down to ½ pack cigarettes daily. Has smoked for 45 years total.

27. Family history: Father is deceased and had a history of hypertension and diabetes; Mother is deceased and had a history of CAD/MI; Sister-history of colon cancer. Discussion Part One: Provide differential diagnoses (DD)with rationale. Further ROS questions needed to develop DD. Based on the patient data provided, choose geriatric assessment tools that would be appropriate to use in conducting a thorough geriatric assessment. Provide a rationale on why you are choosing these particular tools. *******************************************************8

28. NR 601 Week 4 Case Study Discussions(Part-2) For more course tutorials visit www.tutorialrank.com Discussion Part Two (graded) Physical examination: Vital Signs: Height: 5’8” Weight: 188 pounds BMI: 28.58 oral P: 72 regular R: 24, pursed-lip breathing; Pain level-7-right shoulder BP: 130/70 T: 99.0 HEENT: Normocephalic, symmetric. PERRLA, EOMI, cerumen impaction bilateral ears.

29. NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. LUNGS: Labored respirations; posterior RLL, LLL, RML, LML diminished breath sounds. Rhonchi right and left anterior chest. HEART: RRR with regular without S3, S4, murmurs or rubs. ABDOMEN: Normal contour; active bowel sounds, LLQ tenderness. PV: Diminished pedal pulses; hair loss noted over extremities. NEUROLOGIC: Negative GENITOURINARY: Urinary dribbling, urgency, gets up 4 times during the night, distended bladder. MUSCULOSKELETAL: Limited ROM in right shoulder. Crepitus in knees bilaterally. PSYCH: Negative

30. SKIN: Negative Discussion Part Two: Summarize the history and results of the physical exam. Discuss the differential diagnosis and rationale for choosing the primary diagnosis. Include one evidence-based journal article that supports your rationale and include a complete treatment plan that includes medications, possible referrals, patient education, ICD 10 Codes, and plan for follow up. *******************************************************8 NR 601 Week 5 Case Study Discussions (Part-1) For more course tutorials visit www.tutorialrank.com

31. Discussion Part One (graded) C.W. is a tall, thin 78-year-old African American male brought into the office by his son who states that the patient is restless, angry, and has been unable to sleep for the last week. The son indicates that he is very concerned about his father because he lives alone. Also, he is concerned about the “strange” symptoms that his father has presented with recently. Background: C.W. presents as restless, hyperverbal, obnoxious and angry. He expresses himself by periodic yelling. He is unkempt and smells strongly of urine, alcohol and body odor. ………… has an unsteady gait and sways while standing. As you converse with the son, you determine that C.W. was medically separated from military service due to mental health issues after 2 years of active duty that ended in 1947. He has been married and divorced three times over the years. He typically seeks no acute or preventative medical care. ___ was treated by a psychiatrist previously, but he did not like taking the prescribed medications so he

32. stopped taking them and did not keep any further psychiatric appointments. PMH: Patient denies any previous diagnoses. However, when asked why he saw a psychiatrist in the past, he tells you that the psychiatrist diagnosed paranoid schizophrenia, but that he does not have any psychiatric diagnoses or problems. He states: “It was just a way for him to make money off me coming in and seeing him and paying the drug companies for me to take all those meds!” Current medications: Denies prescription medications, over the counter medication, herbal therapies or vitamins. Surgeries:

33. Denies surgeries Allergies: NKA Vaccination History: Flu vaccine: never given Pneumovax: never given Tetanus: never given Herpes zoster: never given Screening History: Last Colonoscopy was 2012-normal

34. Last dilated retinal and glaucoma exam was 2013 Social history and Risk Factors: Patient admits to smoking cigarettes and cigars. …… estimates that he smokes about 1 pack of cigarettes daily for the last 40 years, and 2 cigars each week for the last 30 years. He states that he drinks a 24 ounce bottle of beer 4-6 times a week. … denies drinking wine or hard liquor. …….. does admit to smoking marijuana on occasion but does not use other recreational drugs. Patient denies falling. You notice some scrapes on his forearms, and when asked, he tells you that he fell yesterday: “I got pretty drunk out fishin’ with friends and fell off my bike trying to ride home”. He does not use any assistive devices for ambulation or balance. Significant ROS:

35. Productive cough with white sputum. Denies hemoptysis. He answers “No” to the PHQ-2 screening questions. Family history: Reports no significant family history Discussion Part One: Provide differential diagnoses (DD) with rationale. Further ROS questions needed to develop DD. Based on the patient data provided, choose geriatric assessment tools that would be appropriate to use in conducting a thorough geriatric assessment. Provide a rationale on why you are choosing these particular tools. *******************************************************8

36. NR 601 Week 5 Case Study Discussions (Part-2) For more course tutorials visit www.tutorialrank.com Discussion Part Two (graded) Physical examination: Vital Signs: Height: 5’8” Weight: 154 pounds BMI: 23.4 BP: 132/76 P: 76 regular R: 16 HEENT: Normocephalic, symmetric. PERRLA, EOMI, no cataracts noted; poor dentition.

37. NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. LUNGS: Respirations are unlabored, decreased breath sounds and crackles at the bases bilaterally. Prolonged expiratory phase throughout lung fields, inspiratory wheezes and a productive cough of cloudy white sputum. HEART: RRR with regular without S3, S4, murmurs or rubs. ABDOMEN: Round, firm abdomen; active bowel sounds; non-tender. NEUROLOGIC: Unsteady gait, swaying while standing during periods of agitation. Achilles reflexes are present bilaterally. Strength is equal but decreased in the upper and lower extremities bilaterally. GENITOURINARY: Urinary incontinence with strong odor of urine. NO CVA tenderness. MUSCULOSKELETAL: Mild kyphosis. Heberden’s nodes at the distal interphalangeal joints (DIP) of all fingers, and marked crepitus of the bilateral knees on flexion and extension. Pedal pulses palpable. No edema noted in lower extremities.

38. PSYCH: Manic, restless, angry and hyperverbal SKIN: Right forearm with 3 cm x 5 cm x 0 cm dry, scabbed abrasion. Left forearm with 4 cm x 5 cm x 0 cm dry, scabbed abrasion. *******************************************************8 NR 601 Week 6 Case Study Discussions Health Promotion, Health Protection, Disease Prevention, and Treatment Considerations in Long-Term Care (Part-1) For more course tutorials visit www.tutorialrank.com Discussion Part One (graded) Ms. S. is a 62-year-old black female who has returned to the clinic to discuss her concerns that her lifestyle modifications to lose weight have not worked. At the last visit 3 months ago, she was advised to change

39. her eating habits and increase activity to promote weight loss. She reports walking at least 30 minutes a day but has lost very little weight. ……….. indicates that the walking only made her extremely thirsty and hungry and attributes her increased thirst and hunger to increased exercise and her increased urination due to drinking more water since “it’s been hot lately” and exercise makes me thirsty”…… has returned to the clinic to discuss if there is anything else that can be done to lose weight and to determine why she is so tired, thirsty and hungry all the time. She also thinks she may have an overactive bladder since she has to urinate frequently during the day, which has influenced her not to go on outings with her friends. Discussion Questions Part One Conduct a ROS on this patient. Indicate which symptoms are most concerning to you. List your differential diagnoses. What types of screenings would be appropriate to use based on the chief complaint? What primary diagnosis are you choosing at this point?

40. *******************************************************8 NR 601 Week 6 Case Study Discussions Health Promotion, Health Protection, Disease Prevention, and Treatment Considerations in Long-Term Care (Part-2) For more course tutorials visit www.tutorialrank.com Discussion Part Two (graded) Physical Exam: Discussion Part Two (graded) Vital signs: blood pressure 145/90, heart rate 100, respirations 20 height 5’1”; weight 210 pounds

41. Labwork: CBC: normal UA: 2+ glucose; 1+ protein; negative for ketones CMP: BUN/Creat. elevated; Glucose is 300 mg/dL Hemoglobin A1c: 12% Thyroid panel: normal LFTs: normal Cholesterol: total cholesterol (206), LDL elevated; HDL is low EKG: normal General: obese female in not acute distress HEENT: unremarkable

42. CV: S1 and S2 RRR without murmurs or rubs Lungs: Clear to auscultation Abdomen– soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits Discussion Questions Part Two For the primary diagnosis, what non-pharmacological and pharmacological strategies would be appropriate? Include the following: lab work and screenings to be completed. Describe patient education strategies. Describe follow-up and any referrals that may be necessary. *******************************************************8

43. NR 601 Week 7 Case Study Discussion Health Promotion, Health Protection, Disease Prevention, and Treatment Considerations in End-Of-Life Care (Part-1) For more course tutorials visit www.tutorialrank.com Discussion Part One (graded) C.G. is a 69-year-old male with a history of right head and neck cancer that you have been following for one year. The carcinoma was initially localized to the head and neck-specifically at the left lingual tonsil region and went on to complete a total of 6 weeks of radiation and chemotherapy. Recently, the last PET scan indicated some metabolic activity in the left lymph node area along with other regions of abnormal metabolic activity in the body-particularly the liver and the lungs indicating metastasis. C.G. indicates that he is tired of the effects of chemotherapy and radiation and does not want to pursue any more treatment for cancer.

44. Background: Right head and neck cancer with metastasis to liver and lungs; patient is refusing further treatment. PMH: Hypertension Hyperlipidemia Stomatitis Anemia Neutropenia Current medications: Carvedilol 12.5 mg po 1 daily

45. Furosemide 40 mg po daily Surgeries: 2012: right radical neck dissection Allergies: None Vaccination History: Influenza vaccine last received 1 year ago Received pneumovax at age 65 Received Tdap 5 years ago Has not had the herpes zoster vaccine

46. Social history and Risk Factors: Former smoker-stopped smoking at the time his cancer was diagnosed-2 years ago Negative for alcohol intake or drug use Patient does not have an advanced directive or living will. He is refusing further treatment for his cancer and his wife and children are in disagreement with him. The patient wants to know what his options are for the remainder of his life. Family history: Negative Discussion Part One: Provide differential diagnoses (DD) with rationale. Further ROS questions needed to develop DD.

47. Identify the legal/ethical issues involved with the patient and describe your approach to addressing end-of-life care for this patient. *******************************************************8 NR 601 Week 7 Case Study Discussion Health Promotion, Health Protection, Disease Prevention, and Treatment Considerations in End-Of-Life Care (Part-2) For more course tutorials visit www.tutorialrank.com Discussion Part Two (graded) Physical examination: Vital Signs: Height: 6’0 Weight: 140 pounds; BMI: 19.0 BP: 156/84 P: 84 regular R: 20 HEENT: normocephalic, symmetric PERRLA, EOMI; poor dentition

48. NECK: left neck supple; non-palpable lymph nodes; no carotid bruits. Limited ROM LUNGS: rhonchi in anterior chest bilaterally. HEART: S1 and S2 audible; regular rate and rhythm ABDOMEN: active bowel sounds all 4 quadrants; Normal contour; RUQ tenderness; liver palpable NEUROLOGIC: negative GENITOURINARY: negative MUSCULOSKELETAL: negative PSYCH: PHQ-9 is 15 SKIN: oral mucosa irritated-stomatitis Discussion Part Two: Summarize the history and results of the physical exam. Discuss the differential diagnosis and rationale for choosing the primary diagnosis. Include one evidence-based journal article that supports your rationale and include a complete treatment plan that includes medications, possible referrals, patient education, ICD 10 Codes, and plan for follow up. *******************************************************8