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SafetyNurse1968 ADN, BSN, MSN, PhD

Oncology, Home Health, Patient Safety

If I were in charge of the universe, there would be staffing ratio laws and unions in every state and you'd get written up for NOT taking your breaks.

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

Kristi Sanborn Miller RN, PhD, CPPS, HNB-BC is A Patient Safety Specialist. She just finished her doctorate in nursing at East Tennessee State University. She is an Assistant Professor at the University of South Carolina -Upstate. She is also a mother of 4 and loves being in the woods of Western North Carolina, when she's not obsessing over patient safety research. Kristi is a board certified professional in patient safety, and a published author. She has over 10 years of experience in nursing in areas like oncology, integrative health and home health with over 20 years of experience in education.

SafetyNurse1968's Latest Activity

  1. SafetyNurse1968

    A Fracture from a Fall: What’s Going on Here? | Case Study

    She says she hit her head on a rock when she fell.
  2. SafetyNurse1968

    A Fracture from a Fall: What’s Going on Here? | Case Study

    When the patient is asked about contacting her daughter she says, "Oh dear me no, I don't want to bother her." She refuses to give any contact information for her daughter. Patient states, "I must have hit my head on a rock in the garden. The bruise is from running into a doorknob - I am so clumsy." Scans and more info coming... Thanks so much for all the questions and input.
  3. Disclaimer: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills. If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. Chief Complaint “I was working in the garden, and I tripped and fell and hit my head. It was so stupid of me to leave my rake lying on the grass. I’m sorry to bother you, but I couldn’t get it to stop bleeding. I hope it’s not too bad.” General Appearance Patient is thin and appears her stated age. She is wearing clothing with frayed edges and there is a stain on her shirt. Her socks are mismatched. She moves slowly and carefully. She holds a bloodstained washcloth to her right temple. She doesn’t make eye contact and is restless – she fidgets and keeps folding and unfolding the sheet on the gurney. Past Medical History Occasional constipation Arthritis in hands and feet Depression Family History Both parents deceased, father died from CVA at age 77, Mother developed Alzheimer disease in late 70s and died when she was 83. Brother died from heart disease at age 72 Social History Lives with only daughter, age 53 Has been widowed for 15 years (husband died of cancer) Does not smoke or drink alcohol Medications Ibuprofen 200 mg q 4h PRN Docusate sodium 100 mg po BID Citalopram 20 mg PO qday Allergies Co-tromoxazole = rash Review of Systems: (only abnormal values presented) Skin Skin is pale and dry with senile lentigines, poor skin turgor HEENT Dentures present, small abrasion to right upper lip, patient states, “I can’t find my glasses.” Lungs/Thorax Mildly increased chest AP diameter with mild kyphosis Musculoskeletal Healing bruise noted on left upper arm Pain is rated at 7/10 in right temple and 5/10 in her hands and knees. “My arthritis is paining me today.” Upon examination, there appears to be a laceration to the right frontal lobe above the right eye, with a hairline fracture and a small amount of continuous bleeding. Vital Signs BP 141/93 sitting, RA 138/88 standing LA HR 90 (60-90) seated, 95 standing RR 20 (12-14) T 98.9oF HT 5’ 2” WT 95 lbs BMI 17.4 Laboratory Test Results (normal values) Na 146 meg/L (135-145) K 4.8 meq/L (3.5-5) Cl 111 (101-112) Mg 2.8 mg/dL (1.8-3) PO4 4.2 mg/dL (2.5-4.5) BUN 21 mg/dL (8-20) Cr 1.2 mg/dL (0.6-1.2) Ca 9.0 mh/dL (8.5-10.5) Hb 12.8 g/dL females (12-15.5) Hct 36.2% females (35-45%) Plt 290,000 cu/mm (150,000-450,000) WBC 8,000 x 103/mm3 (4,800- 10,800) Glu fasting 62 mg/dL (60-110) Total Protein 6.0 g/dL (6-8.3) Albumin 2.7 g/dL (3.4-4.7) Prealbumin 10 mg/dL (15-36) Urinalysis pH 6.2 (5-6.5) Specific gravity 1.035 (1.016-1.022) Negative for white/red blood cells, proteins, ketones,bacteria or glucose Urine is dark yellow with strong odor What is going on with this patient besides a fracture? What labs do you want? What other diagnostic tests should we run? Ask me some questions! REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.
  4. SafetyNurse1968

    Breathless, Coughing and Run-down: What's Going On? | Case Study

    Ativan salt-lick for everyone! Seriously - much appreciation to everyone for continuing to read and participate - you all make it so much more interesting when you get involved. THANK YOU!
  5. Disclaimer: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills. If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. Chief Complaint “For the past few days I’ve been feeling run-down. I can’t stop coughing and I’m out of breath. It can’t be COVID – I already had it a few months ago.” History of Present Illness The patient has struggled with homelessness for many years. He visits the free clinic every few months, most recently to be treated for Chlamydia and Gonorrhea after experiencing painful urination and swollen testicles. He states that his symptoms “came on fast.” General Appearance Patient is thin and sunburned. He looks more than his stated age, with many wrinkles and burst blood vessels in his nose. His clothing is too large and there is dirt on his pant legs, the creases in his neck and under his fingernails. His hair is long and tangled and in a ponytail. He appears sober and smells of body odor and cigarettes. Past Medical History RSV at 6 months Treated for tuberculosis for 12 months with isoniazid 5 years ago Perianal ulceration, positive for herpes 4 years ago topically treated with acyclovir and zinc oxide MVA resulting in multiple herniated discs and fractures to spine 3 years ago Tested positive for COVID-19 after experiencing mild fever and cough – he got tested when he lost his sense of smell 6 months ago Chlamydia and Gonorrhea 3 months ago, treated with ceftriaxone and azithromycin. Family History No history given Social History Homosexual, admits to engaging in unprotected intercourse since the age of 18. He lives on and off with his 60 yo aunt “until she kicks me out.” He is unemployed and receives social security disability checks for back pain related to the MVA. He previously had worked for several different gas stations He smokes at least one pack of cigarettes a day “if I can get them.” He has a history of alcohol, cocaine, heroin and methamphetamine abuse. Immunizations Had tetanus shot over 10 years ago but can’t recall any others. He does have a COVID-19 vaccination card. “When I found out I could win the lottery, I went right in.” Medications None Allergies Red rash with Sulfa drugs Vital Signs BP 133/83 sitting, LA HR 91 RR 30 T 101.8o F HT 6’ 3” WT 150 lbs BMI 18.7 What information do you need for a diagnosis? What labs do you want? What other diagnostic tests should we run? REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.
  6. Disclaimer: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills. If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. Chief Complaint Suicidal ideation, fatigue, difficulty concentrating, memory lapses and muscle twitches. History of Present Illness “My children begged me to come in. They are so worried about me. The other day, my son started yelling at me – he said I had been standing in front of the open….um…oh what is it called…where you keep your food cold…for 20 minutes, just staring.” Patient states she has been experiencing symptoms for more than a year. “They came on so gradually. I used to be such an upbeat, happy person. My best friend called me a few months ago and I couldn’t remember her name, so I stopped returning her calls. I’ve been thinking lately about ending it all. I just can’t take it anymore, but my kids need me.” She can’t think of any precipitating reason for onset of symptoms. She states low mood and other mental symptoms began over a year ago, muscle twitches have been happening for at least 6 months. General Appearance She appears her stated race, age and gender. She is slender with short hair and a downcast expression. She doesn’t make eye contact and her clothing is wrinkled and stained. “I’m sorry for how I look. I just can’t seem to find the energy to do anything.” During her assessment you notice her head jerk to the side (toward the right shoulder) and she flexes her fingers continuously. Past Medical History Unremarkable. No complications with either pregnancy. Family History Patient was adopted when an infant. Her family history is unknown because she was found in a basket at the local fire station when she was only three weeks old. She has been divorced for five years and has a 21 yr-old daughter who is away at college and a 17 yr-old son who lives at home. Her adoptive parents are alive and well and living 1000 miles away. Social History Drinks 5- 6 alcoholic beverages weekly, smokes 3 cigarettes per day. “I’m trying to quit. I’m down from half a pack a day 6 months ago.” She works from home as a medical coder. “I’ve had to take a lot of time off. I can’t seem to concentrate. I’m worried I’m going to get fired.” Medications Multi vitamin, occasional acetaminophen for headaches, melatonin for insomnia Allergies NKA Vital Signs BP 138/80 sitting, LA HR 70 and regular RR 18 unlabored T 98.8oF HT 5’4” WT 110 lbs What information will help with diagnosis? What labs do you want? What other diagnostic tests should we run? Reminder... DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.
  7. Negative
  8. Admin- directions are on first page
  9. FIRST FOLLOW UP POST: Answers to your questions (thanks for your patience!) Abdominal complaints, bloating or explosive flatulence? No Is there any pattern to the diarrhea episodes, such 30 minutes after a meal, or at night when lying down? No Diet: Patient denies food allergies. She states she tried an elimination diet and has been tested for food allergies with no useful information and no relief of diarrhea. Are there any patterns, such as diarrhea after fatty meals? No Has a sensitive gut diet been tried to see if symptoms are reduced, minimized, or eliminated? No Has the thyroid been fully evaluated by imaging and blood work? Yes - negative Any hardware implanted with jaw surgery? No Scarring noted on elbow and knee. What type of scars? Secondary intention on knee, Surgical scar on elbow Any changes in taste or smell, poor appetite, changes in her nails, hair, or skin? No Has a Fecal microbiota transplantation (FMT) treatment been attempted as part of her care? No Has she had a psychiatric assessment? No No foreign travel What was her weight status prior to the accident and subsequent jaw surgery? 18.5 prior to accident A week after the visit, only the medical records from the most recent medical visit during which she had severe bleeding and a blood transfusion have been received. Laboratory Test Results (normal ranges are listed to the right of each value): Na 144 meg/L 135-145 K 4.4 meq/L 3.5-5 Cl 112 meq/L 101-112 Mg 2.3 mg/dL 1.8-3 PO4 3.5 mg/dL 2.5-4.5 Ca 10.1 mg/dL 8.5-10.5 BUN 23 mg/dL (8-20) Cr 1.3 mg/dL (0.6-1.2) Glu fasting 68 mg/dL (60-110) TSH 3.7 uU/mL (0.4-6) FT4 16 pmol/L (9-24) PTH 35 pg/mL (11-54) Hb 12.3 g/dL females (12-15.5) Hct 35.5% females (35-45%) Plt 210,000 cu/mm (150,000-450,000) WBC 7.8 x 103/mm3 (4,800- 10,800) UA: Specific gravity 1.034 (1.016-1.022) Dark in color pH 7.3 No protein, glucose, ketones, casts, RBCs or WBCs Thin layer chromatography tox screen: positive for bisacodyl Stool: severe secretory diarrhea, (-) blood, (-) leucocytes and (-) bacterial pathogens
  10. SafetyNurse1968

    Nurses Refusing to Administer COVID-19 Vaccinations!? | Nurses Week Contest

    I was taught in nursing school that you had to have a compelling reason to refuse in assignment. I remember this being especially important when considering race, it’s been a while but don’t you remember discussing whether or not you could refuse an assignment because the patient was someone you just didn’t want to take care of? I recall as a new nurse I had a patient who was a child abuser, and I was pretty disturbed by that and I talked to my charge nurse about how I really didn’t want to care for the patient. I remember seeing in her eyes how disappointed she was in me that I wasn’t able to compartmentalize.
  11. Month-Long Nurses Week Celebration Starts Today! Nurses Week Contest #4 Healthcare professionals have expressed vaccine hesitancy due to fear, mistrust, and misinformation. Although nurses are entitled to their opinion, should this influence them when it comes to administering vaccines? Should nurses be allowed to refuse to administer COVID vaccines? What do YOU think? The best Pro or Anti Vaccine read will win $100 Amazon Gift Card courtesy of allnurses Ebooks. Contest rules are found below. More Nurses Week Contests Vaccine Controversy There’s a lot of controversy about the COVID-19 vaccines. I’ve seen articles about how it causes infertility, autoimmunity and even death. Almost 50% of my students have expressed vaccine hesitancy due to fear and misinformation. Some of them have told me they are immunocompromised, and one said that their religion forbids vaccination. Most of them said, “I just want to wait and see if it’s safe.” Are vaccinations safe? There’s been a huge debate for years over whether vaccines cause health problems. When I was about to give birth back in 2009, I did my own research to be absolutely sure that vaccinating my newborn was the way to go. I found no evidence then that vaccination causes autism, and there’s even more evidence now that there is no link between autism and vaccines or any of their ingredients (like thimerosal, which was removed from all vaccines except multi-dose flu vaccines by 2001)1 The flu shot gave me the flu… You’ve probably heard someone say, “I got the flu vaccine once, and it gave me the flu – I’m never getting it again.” What they don’t realize is that 1) the flu vaccine cannot give you the flu and, 2) in these cases, the person had already been exposed to the flu when they got vaccinated. The development of the flu would have occurred regardless of the vaccination. Modern vaccines are constructed in such a way that they cannot cause the disease for which you are being vaccinated against. What about the COVID-19 vaccines? As I stated in the summary, there’s a lot of misinformation about the COVID-19 vaccines including that they cause infertility or autoimmunity.2,3 In addition I have read that they contain a tracking chip and that the RNA from the Moderna and Pfizer vaccines can modify your genes. There is no evidence that any of these assertions are true.4 Though there may be small, isolated cases of side effects occurring with vaccines, they do not outweigh the very real danger of becoming significantly ill from COVID-19. Right now, all the vaccines being used in the US (Moderna, Pfizer and Johnson & Johnson) have 100% efficacy in preventing hospitalization and/or death from COVID-19. Millions of people have been safely vaccinated against COVID-19, and while the evidence is still out as to whether those of us who have been vaccinated can give it to others, we do know that it is working to prevent hospitalization and death from COVID-19. mRNA technology such as that used in the Moderna and Pfizer vaccines has been around for over a decade. You may recall from A&P or biology that mRNA is made in your body from DNA. The way it works in your body is: Segments of your DNA (called genes) code for mRNA (transcription) and then mRNA codes for proteins (translation). An mRNA vaccine enters your body and is translated into proteins that elicit an immune response. There’s no machinery or ability for your body to incorporate the mRNA into your genetic code. Once it’s translated, the mRNA just gets destroyed by catalytic enzymes.5 It’s also important to note that despite the vaccines being offered under emergency use authorization (EUA), “For this EUA, the FDA required significantly more data on safety and efficacy than usual,” said Janis Orlowski, MD, chief health care officer at the AAMC.5 No serious health problems were reported by the tens of thousands of people who received their vaccines during clinical trials. The most common side effects — fatigue, headaches, chills, and muscle pain — lasted about one day and most often occurred after the second dose. Since the vaccine rollout began in the U.K. and U.S., there have been sporadic reports of severe reactions in people with histories of significant allergic reactions to some foods and drugs.6 Our duty as nurses The American Nurses Association supports that all nurses get vaccinated for COVID-19.7 The Code of Ethics for Nurses Provision 3 states, “The nurse promotes, advocates for and protects the rights, health and safety of patients.” Not getting a flu vaccine can result in increased risk of contracting flu for patients, co-workers and yourself. Despite this, nurses do refuse to take the flu vaccine – usually due to religious, medical or philosophical objections. Only 21 states have a law that requires healthcare workers to get flu vaccinations and even those laws require exemptions be allowed. Many employers mandate a flu shot, but also allow exemptions. About 1/3 of states require hospitals to offer employees flu shots and track their vaccination status. In many of these states, employees can decline a flu shot without an exemption.8 But what about the COVID-19 vaccines? Can those be required? The federal government says that COVID-19 vaccination can be required, but so far no healthcare organizations have taken this confrontational stance.5,6 I believe we have a duty as nurses to get vaccinated against COVID-19 to protect our patients and coworkers and also to prevent mutations/variations in the vaccine. We all need to work together to eradicate COVID from the planet. My Question: Can a nurse refuse to GIVE the vaccine? In nursing school, I recall an ethical debate on whether or not a nurse could refuse to care for a patient having an abortion. We decided that nurses should have the right to refuse to take part in an abortion based on moral objection, though once the pregnancy is terminated, the nurse should no longer be able to refuse to give care. Does that translate to giving vaccinations? If a nurse is morally opposed to vaccinations, can they refuse to give them? I googled “Can a nurse refuse to administer vaccines” and all I came up with was a list of articles about how many nurses are refusing to get the vaccine. It’s hard to find information on this topic. What do you think? Should a nurse be allowed to refuse to give vaccinations? Should the reason for that opposition play a role (religious, ethical, moral, philosophical)? Contest Rules Open to registered allnurses.com members only. (Free and quick to Register) Participate in the Poll. Answer 'Should a nurse be allowed to refuse to give vaccinations? Why?' One winner will be announced. This contest is sponsored by allnurses Ebooks. Quality Nursing Ebooks. Anytime. Anywhere. Our ebooks are created by nurses, educators, students, and healthcare professionals. We have one goal - To help you succeed in your nursing career. References 1 Autism and vaccines 2 Why the vaccinations do NOT cause infertility 3 Vaccine myths 4 The vaccine does not cause autoimmune disorders 5 Association of American Medical Colleges: What health care workers need to know 6 COVID-19 vaccine safety 7 ANA position statement on vaccines 8 Becker’s flu shot requirements
  12. Month-Long Nurses Week Celebration Starts Today! Nurses Week Contest #1 Test your knowledge and clinical investigative skills in trying to diagnose what is going on with the patient who has presented with Unexplained Diarrhea and Weight Loss. Can you come up with the right diagnosis? The winning participant will win $100 Amazon Gift Card courtesy of University of Maryland! More Nurses Week Contests Disclaimer: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills. Contest Rules Please follow the rules. All participants will be entered to win a $100 Amazon Gift Card. Open to registered allnurses.com members only. (Free and quick to Register) Participation will earn you 1 entry. Do NOT post your answer here. Post your answer in the ADMIN HELP DESK.* One winner will be announced during Nurses Week. If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. *Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. Chief Complaint “I’ve had diarrhea now for 3 years and I keep losing weight.” Patient also complains of a racing heart, headache and dizziness. History of Present Illness Diarrhea began a few days after the patient had reconstructive jaw surgery. The patient states that extensive evaluation at two institutions failed to reveal a cause of her illness. She states, “My stool weighed 1008 grams each day (normal weight for women is 87 +/- 8 g/day). The diarrhea was secretory in nature without steatorrhea. They did biopsies, x-rays, upper and lower endoscopy and they found nothing…no melanosis coli, ruled out microscopic colitis, small bowel disease…and my serum gastrin and VIP were within normal limits. I also had no pathogens in my stool culture.” About two years after onset of diarrhea, she went to another medical center where diagnostic tests were repeated with no diagnosis. After a colonoscopy she had severe bleeding and required multiple units of blood and her weight dropped to 108 pounds. At that time total parenteral nutrition was begun until she healed. General Appearance Patient appears thin and pale. She has a thick notebook full of notes which she refers to when discussing her medical history. She has to be interrupted repeatedly to get pertinent information, and she smiles and giggles occasionally while talking about her illness. Past Medical History No significant medical or psychiatric history other than fractured right jaw after MVA three years ago. Family History Patient has been married for four years. Mother is 65 with hypertension and obesity. Father is 72 with CAD and hypercholesterolemia. Patient has no siblings. She states, “My father abused me and my mother and I don’t talk to him. He used to hit us. My homelife was terrible.” Social History The patient lives with her husband. She smokes, stating, “only 1 or 2 a day” and drinks wine once or twice a week. Denies recreational drug use. She is enrolled in an online graduate school program and studying biology. “My husband works all day, so I’m alone a lot. I’d really like to go to medical school, but I’m just not sure I could do it because of my health.” Medications Denies taking any medications Allergies Penicillin, radiocontrast, aspirin Review of Systems Only abnormal values presented Skin: Pale, dry, scarring on right jawline, right elbow and left knee. Vital Signs BP 125/70 sitting, LA HR 92 RR 20 T 98.7o F HT 5’6” WT 110 lbs BMI 17.8 What information do you need to help this patient with a diagnosis? REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information. This contest is sponsored by University of Maryland. Earn your MSN online from anywhere: Join one of the nation’s top-ranked Nursing Informatics or Health Services Leadership and Management programs. Pay in-state tuition in 15 states, and we’ll arrange your practicum placement for you. Become a leader in the conceptualization, design, and research of digital information systems or in nursing leader and management, business, or education. Full-time and part-time options available.
  13. Disclaimer: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills. If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. Chief Complaint The patient is a white male who states he is 25 years old. He has a deep laceration on his left knee and says, “I was running after this guy who really pissed me off, and I fell.” You notice that he mimics your behavior as you clean and bandage his wound. He occasionally repeats words you have said and loses focus, but answers questions after prompting. History of Present Illness You ask him if he is aware that he is mimicking your actions and words and he says, “Yeah, it’s just something I do. It kinda drives people crazy.” He says he can’t recall a time when he didn’t engage in mimicry. You ask, “Can you stop doing it if you try?” He responds, “If you try. I get all itchy and antsy…I feel better when I just do it.”. He states that he doesn’t sleep much. When you ask if he has a history of fighting, he says, “I get into fights when I have to. People make me mad, they really do.” General Appearance Patient appears older than his stated age. His skin is red and rough. His clothing is dirty and mismatched, and he has dirt under his fingernails and embedded in the skin around his shirt collar and ears. He blinks repeatedly during the interview and appears agitated, especially when talking about his altercation with the man he was chasing. He has difficulty sitting still and frequently looks around the room. He sighs heavily and taps his legs with his fingers. Past Medical History The patient states he broke his left arm. “I was a kid. I fell out of a tree I think.” He denies any other medical or psychiatric diagnoses. Family History Patient is unaware of any family medical history. “I haven’t talked to my family since I left home.” Social History The patient states he has been homeless since he was 17 when he ran away from home. “I like it out here – it’s better for me. My parents just didn’t get me.” He admits to drinking daily. “Whatever I can get. It helps, you know?” He uses recreational drugs and cigarettes when they are available but denies addiction. He is an only child. He says he has friends who he sees around town, but no one he feels close to. He dropped out of school when he was 16. Medications None Allergies NKA Vital signs BP 118/74 sitting, LA HR 76 RR 16 T 97.5oF HT 5’ 11” WT 170 lbs What information would help you rule out or refine a diagnosis? Remember, most healthcare facilities want to start with the least invasive and least expensive tests. For example, a CT scan usually won’t be approved before a CBC and Chemistry are done. I look forward to your questions! REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.
  14. If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. Disclaimer: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills. Chief Complaint A 50-yr-old male of mixed-race states that over the past six months he has been experiencing mood swings and outbursts of anger. “I’m out of control. One minute I’m happy and the next I’m furious. I’ve been screaming at my poor husband. The other day I even pushed him, and all he did was break my favorite coffee mug. I didn’t push him hard, but it frightened me. My dad used to knock my mother around and I don’t want to be like him. If I sit still for too long, I start thinking about all the bad things in my life and my heart starts racing. It feels sometimes like the world is coming to an end. I don’t understand what’s going on – I’m a happy person. I hope I don’t have a brain tumor or something.” History of Present Illness Patient states that after pushing his partner last week, they sat down and talked about the incident. “My husband helped me realize that I’ve been getting worse. I hadn’t realized it, but when I think back I can recall these feelings being around for at least 6 months. I think I’ve been in denial.” Patient has gained 20 lbs since his last visit 9 months ago. General Appearance Patient appears tired and is tearful. His skin is light brown in color, and he appears to be slightly overweight, though he is also muscular. He has male pattern baldness and wears glasses. His hair is cut short and he is clean-shaven and appropriately dressed. Speech is rushed at times, but content is normal. Patient has difficulty making eye contact during assessment. Past Medical History Unremarkable Family History Father died from colon cancer 5 years ago at the age of 67. Patient states his friends from back home report his mother is alive and well. His only sibling, a brother died of an opioid overdose at age 41. No other known family history of mental illness. Social History The patient has been married to his partner for over ten years He and his partner are physically active and enjoy hiking and gardening together. Eighteen months ago, his brother died of an overdose. He became estranged from his parents fifteen years ago after coming out. “My brother kept me posted about my father’s illness, but they didn’t want me to visit. I wasn’t invited to the funeral. Now there’s no chance for reconciliation. I don’t even know if my mother knows where I live. I really wish she could accept me for who I am. I was close to my brother – I really miss him. The last few years have been hard.” Patient drinks 1-2 beers several times a week, has never smoked. “I used to party pretty hard in college, but I don’t use drugs anymore, not with my brother’s situation. It just seemed wrong.” The patient is an attorney for a low-cost legal service in his county. His partner is an elementary school teacher. They are very active in their Unitarian Church. Medications He takes loratadine for allergies and atorvastatin for high cholesterol. Allergies NKA Questions Is there a mental health diagnosis that fits these symptoms? If not, what’s causing his mood swings and outbursts of anger? What about the weight gain, racing heart and feelings of worry? What information could you ask for that would give you the most information for a diagnosis? What labs do you want? What other diagnostic tests should we run? Ask me some questions! REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.
  15. If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. Disclaimer: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills. Chief Complaint An 85-yr-old Cherokee woman living in a skilled nursing facility in Western North Carolina (WNC) has been reluctant to socialize or join in activities. She has lost 10 lbs in the month since she has been admitted. Her hair is unwashed and the aids state she often refuses a bath. She takes her meals in her room saying, “I just don’t feel comfortable here. I want to go home.” The patient has complained of not liking the food. Staff members have reported overhearing her talking about getting messages from “plant people.” The cafeteria staff have reported that she questions them constantly about the ingredients in the food and how it is prepared. The cafeteria manager states, “She keeps asking for a bunch of weird TEAS we don’t have, and I don’t know where to get them.” History of Present Illness She was admitted to the facility one month ago due to multiple falls in her home. Her most recent fall resulted in loss of consciousness when she hit her head on the bathroom sink. She currently uses a rolling walker for ambulation. The patient has been observed sleeping or sitting in chair for 90% of day; she refuses to participate in physical activity. Past Medical History Depression x 3 years, osteoarthritis x 12 years and GERD x 3 years Family History One child, alive and well who lives in Oklahoma. Mother died in her 80s from stroke, father died at 60 from acute MI, two sisters, ages 78 and 80 are alive and well and living in Oklahoma. Husband died of MI 6 months ago. Social History After she married her husband 50 years ago, they moved from Oklahoma to WNC where her husband’s family lives. After he died, she tried living on her own in their small home, but she fell several times and her daughter insisted she move into a SNF. No alcohol or tobacco use, no reports of using recreational drugs. She has a history of not taking her medications saying, “I don’t believe in taking a pill for everything that is wrong. A pill can’t teach you anything.” Medications OTC ibuprofen, Esomeprazole and Citalopram. Allergies Cephalexin – severe hives Questions 1- Why is this patient talking about "Plant People"? 2- How would you approach a diagnosis for this patient? 3- What strategies will you need to use for patient centered care? 4- What labs do you want? 5- What other diagnostic tests should we run? REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.
  16. SafetyNurse1968

    Case Study: It’s a Lump, but is it Breast Cancer?

    Diagnosis: Core-needle biopsy of large left breast mass: pathology consistent with invasive ductal carcinoma (infiltrating breast carcinoma), tubules observed in 85% of sample, 3-5 cell divisions in high-power observation with mild pleomorphism, tumor positive for estrogen and progesterone receptors. Ultrasound of left breast and axilla: four cystic lesions in the left breast, solid-appearing, non-cystic mass consistent with cancer in upper outer quadrant, ill-defined mass with abnormal vascularity, the mass measures the same as with the mammogram (2,1x3x3.1 cm), there is some suggestion of skin thickening and mild tissue edema. Ultrasound of liver: clear Bone scan: no definitive evidence of bone metastasis, positive for mild degenerative changes consistent with degenerative joint disease. Invasive ductal carcinoma (IDC), also known as infiltrating ductal carcinoma, is cancer that began growing in a milk duct and has invaded the fibrous or fatty tissue of the breast outside of the duct. IDC is the most common form of breast cancer, representing 80 percent of all breast cancer diagnoses. As with any breast cancer, there may be no signs or symptoms Make an appointment to have a breast lump evaluated if: The lump feels firm or fixed The lump doesn't go away after four to six weeks You notice skin changes on your breast, such as redness, crusting, dimpling or puckering You have discharge, possibly bloody, from your nipple Your nipple is turned inward and isn't normally positioned that way You can feel a lump in your armpit and it seems to be getting bigger Thickening of the breast skin Swelling in one breast New pain in one particular location of a breast Changes in the appearance of the nipple or breast that are different from the normal monthly changes a woman experiences Now that you know the patient has IDC – what’s next? Clinical course: The oncologist met with the patient and together they decided on breast conservation therapy/lumpectomy with sentinel lymph node biopsy, radiation and chemotherapy. The nodes were negative and surgical margins were clear. After radiation treatment, the patient was placed on tamoxifen. She will have follow-up appointments every 3-4 months for the first two years and then every 6 months for the next three years, then annually. For more information on options for treating IDC, check out https://www.breastcancer.org/symptoms/types/idc/treatment Treatments for invasive ductal carcinoma (IDC) include surgery, chemotherapy, radiation therapy, hormonal therapy, and targeted therapy. Surgery is used to treat IDC not only to remove the breast tumor itself, but also to confirm whether or not cancer is in the lymph nodes. Surgery is considered a local treatment because it treats just the tumor and surrounding area. A lumpectomy removes only the tumor (the “lump”) and some of the normal tissue that surrounds it. In a Sentinel lymph node biopsy, the surgeon looks for the very first lymph node — the “sentinel node” — that filters fluid draining away from the area of the breast that contains the cancer. If cancer cells are breaking away from the tumor and traveling away from your breast through the lymph system, the sentinel lymph node is more likely than other lymph nodes to contain cancer. The surgeon uses a special radioactive substance or dye to identify that first node and the couple of nodes where it drains. These nodes are then removed and sent for examination by a pathologist. If the lymph nodes are cancer-free, no further surgery is necessary. If cancer is found, then more lymph nodes in the armpit need to be removed, either now or at a later date. Radiation therapy is most often recommended after surgeries that conserve healthy breast tissue, such as lumpectomy and partial mastectomy. If the IDC is larger than 1 centimeter in diameter and/or has spread to the lymph nodes, chemotherapy is usually recommended or, at the very least, seriously considered. When chemotherapy is given after surgery, it is called “adjuvant therapy.” In cases where the tumor is large, or breast cancer cells have traveled to many lymph nodes or other parts of the body, chemotherapy may be given before surgery to shrink the cancer. This approach is called “neoadjuvant therapy.” In either case, chemotherapy will be given in cycles, usually with a day (or days) of treatment followed by a period of “off” days. The exact schedule can vary depending on the medication or medications used. An entire course of chemotherapy usually takes about 3 to 6 months. Hormonal therapy for IDC is recommended if the cancer tested positive for hormone receptors, Hormonal therapy, also called anti-estrogen therapy or endocrine therapy, works by lowering the amount of estrogen in the body or blocking the estrogen from signaling breast cancer cells to grow. For small tumors, it’s common for hormonal therapy (adjuvant treatment) to be given after other treatments. Tamoxifen acts like estrogen and attaches to the receptors on the breast cancer cells, taking the place of real estrogen. As a result, the cells don’t receive the signal to grow. Tamoxifen can be used to treat both pre- and postmenopausal women. Other examples of SERMs are Evista (chemical name: raloxifene) and Fareston (chemical name: toremifene). References Breast lumps https://www.mayoclinic.org/symptoms/breast-lumps/basics/causes/sym-20050619 Invasive ductal carcinoma https://www.hopkinsmedicine.org/breast_center/breast_cancers_other_conditions/invasive_ductal_carcinoma.html Risk factors for Breast Cancer at a Young Age https://www.CDC.gov/cancer/breast/young_women/bringyourbrave/breast_cancer_young_women/risk_factors.htm?s_cid=byb_sem_013 Treatment for IDC https://www.breastcancer.org/symptoms/types/idc/treatment