06 Dec Case Presentation on Topic: Marfan syndrome Introduction:? Describe

SAMPLE CASE STUDY __—–

Case study of Mr. J with CVA

Introduction:

The patient Mr. J, a 58 years old African-American, admitted in the Emergency Department with complaints of loss of balance followed by the altered level of consciousness (ALOC), left-sided hemiparesis, dysarthria, and facial droop. He denied chest pain, visual disturbances, cephalalgia, trauma, bowel incontinence, urinary incontinence, etc. He had stable vital signs except blood pressure of 150/90 mm of Hg, indicating hypertension. After necessary diagnostic tests, the physician diagnosed the case as a cerebrovascular accident (CVA).

Past Medical History:

Mr. J was diagnosed with diabetes mellitus (DM) type 2 at the age of 40 years. He was taking some herbal remedies at first, but is on antidiabetic agents as per physician's prescription for eight years. He is also on antihypertensives for three years. He also has a history of hypercholesterolemia and gouty arthritis, an inflammatory condition of joints, especially the hallux joint, due to deposition of urate crystals, but he is not on any medications for that. He is having a poor compliance with the medication regimen. Currently, he is taking ACE (angiotensin-converting enzymes) inhibitors, beta-blockers for his hypertension, and an antihyperglycemic agent, Metformin, for diabetes mellitus.

Family History:

Mr. J's father died from myocardial infarction (MI). He had a history of hypertension (HTN), coronary artery disease (CAD), and benign prostatic hyperplasia (BPH). Mother is suffering from diabetes mellitus (DM) and is on insulin. She also has a history of inflammatory bowel disease (IBD).

Disease condition:

Stroke (cerebrovascular accident): The loss of brain function arising from the sudden interruption of cerebral blood supply. It might be of two types; hemorrhagic CVA and ischemic CVA. Hypertension and hyperlipidemia are the two main risk factors of CVA. Other risk factors are smoking, obesity, family history, etc.

The main causative factors are:

1. Thrombosis (clot formation) due to atherosclerotic plaques.

2. Embolism or cardiogenic emboli.

Actions taken:

1. Intravenous (IV) injection of tPA (recombinant tissue plasminogen activator).

2. Administration of antiplatelet blood thinners, aspirin.

3. Vital signs monitoring q.4 hours.

4. Management of intracranial hypertension (IH) with diuretics.

Nursing assessment:

1. Assessment of neurological status to know the severity of CVA.

2. Altered level of consciousness (ALOC).

3. Nuchal rigidity.

4. Assessment for any dysarthria (difficulty in articulating words) and dysphagia (difficulty in swallowing).

5. Skin color of face and extremities.

Results: The wife said, he has now changed towards the better by incorporating healthier meals and less junk food items. She mentions that he has had a difficult time in the past few years with diabetes, hypertension, gouty arthritis, etc. Change in lifestyle along with therapies and the addition of a service dog aided improvements along with his family support system. The patient spends lots of time outside with his dog and has started working on small projects, which keeps him active. She also states that the patient’s HbA1c (glycosylated hemoglobin) has not been tested for almost three months and that it needs to be tested as his RBS (random blood sugar) is high. The patient visits his podiatrist regularly for peripheral neuropathy and is on B vitamins q. daily; however, his neuropathy is on remission since undergoing transcutaneous electrical nerve stimulation (TENS). The patient’s wife is also doubtful about his mental status with increasing forgetfulness pointing towards dementia. She also remembered that he once complained of visual aura while doing gardening and after that he had photophobia for a while. She says he needs to undergo a dilated eye examination to diagnose retinopathy as he is complaining of blurred vision and floaters occasionally with some dry eyes. She says he uses over-the-counter Visine eye drops as a remedy, which she understood is for keratoconjunctivitis sicca.

Assessment results revealed diagnostic evaluation with head CT scan showed ischemic stroke. Blood samples taken revealed hypercholesterolemia with cholesterol level 300 mg/ dL (milligrams per deciliter), high-density lipoprotein (HDL) 40 mg/dL, and low-density lipoprotein (LDL) 150 mg/dL. His fasting blood sugar (FBS), random blood sugar (RBS), or glycosylated hemoglobin were not obtained. He is on Metformin for hyperglycemia.

Results revealed that the patient is having an attack of right-hemisphere ischemic cerebrovascular accident.

Consent: Patient consent was obtained for a detailed eye examination referral.

Lessons Learned: Teachings from this particular case study had information on CVA; symptoms, medications, diagnostic studies, etc. Additionally, the comorbidities were also given, which was helpful to understand the complications that could lead to CVA. If patients don’t have annual eye examinations, they can have visual complications. Psychological well-being is also of much significance when dealing with patients and their families. Complex information is given and the processing time is different from that of medical professionals, so more time should be given to formulate thoughts and doubts that will result in less confusion and better understanding. The likelihood of having a psychological impact on psychological symptoms can’t be disregarded. Overall, maintaining a good patient-caregiver relationship is of utmost significance to healthcare professionals for proper disease management as well as positive health outcomes.

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ATR2205-30 Final Assignment

The final assignment is to write a case study. You will choose a disease from my list; however, you can use some creativity in developing your case if you so desire. For example, for deep vein thrombosis, you could make it something that arose after a long international flight.

I have included links to the National Institutes of Health on the webpage, for you to use as a starting point.

The format you are to use is as follows:

Case presentation:

a) Introductory sentence: A 25-year-old salesman presented with pain in his right leg.

b) Describe the nature of the complaint including location, intensity, and associated symptoms.

a. The pain was throughout the right lower leg. Upon observation, the calf was swollen and red. The pain worsened with walking.

c) Describe the history of the complaint including details of the time and circumstances of the onset. Also, the evolution of the complaint.

a. The patient returned the previous day from a business trip to China. He slept most of the flight and did not walk around the cabin. He was stiff upon exiting the plane but was able to walk and drive his car home. However, he awoke in the middle of the night with wrenching pain. He could not feel his toes.

d) Describe the relieving and aggravating factors.

e) Include other health history.

a. The patient has a history of HTN, is morbidly obese, borderline diabetic…

f) Include family history.

a. The patient’s mother had CHF

g) Summarize the results of physical examination.

a. His BP was 170/110 mmHg, …

h) List tests/diagnostics that are ordered (Do make it relevant to the condition;)

a. MRI of the leg was ordered, CBC, …

i) List a diagnosis

a. The patient was diagnoses with right leg DVT

j) Give some possible treatments (Assume the patient lives long enough for treatment.)

k) Give the general prognosis for this kind of condition

l) List citations (give between 3 and 8) in APA format

Make it at least 200 words long, but no more than 500 words (not including the citations). Use at least 40 medical terms and/or abbreviations.

On a separate list, give the medical word/term definition, and break it into the parts with their meanings.

This should be similar to the case studies that were in the blogs, except with a bit more information on the conditions to add interest and to make it fun! Let me know if you have questions.

Pick 50 medical terms (NOT 100 words) that you learned in class and create a case study in Word. The guidelines for this project are as follows: add more medical terms in this case and keep that word bold and underline those word.

Final Assignment: Case Presentation on Topic: Marfan syndrome

Introduction:

Describe the Nature of the complaint including location, intensity, and associated symptoms.

Describe the History of the complaint including details of the time and circumstances of the onset. Also, the evolution of the complaint.

Describe the Relieving and aggravating factors.

Patient history.

Family history.

Summarize the Results of Physical Examination.

List Tests/diagnostics that are ordered. (Do make it relevant to the condition;)

List Diagnosis

Give some Possible treatments. (Assume the patient lives long enough for treatment.)

Give the general Prognosis. for this kind of condition

List citations (give between 3 and 8) in APA format

Make it at least 200 words long, but no more than 500 words (not including the citations). Use at least 40 medical terms and/or abbreviations.

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ATR2205 Final Assignment Rubric

Item	Satisfactory	Unsatisfactory
Introduction	10	0
Nature Complaint	10	0
History Complaint	10	0
Relieving/Aggravating Factors	10	0
Patient History	10	0
Family History	10	0
Results of Physical Examination.	10	0
Tests/diagnostics that are ordered.	10	0
Diagnosis	10	0
Possible treatments.	10	0
Prognosis.	10	0
Citations.	10	0
40 medical term definitions	80	0
TOTAL