NR 511 Assignments, Case Study Discussions
Further questions and Why? Follow OLDCARTS first then you can ask
additional questions r/t your specific differentials.
O: Onset: One day ago. Did the symptoms come on suddenly?
L: Location: HEENT, legs. Do you fell achy all over your body?
D: Duration: Are you symptoms continuous or intermittent? Have you
ever had symptoms like this before?
C: Characteristics/Associated Symptoms: a runny nose, watery eyes,
cough, headache, tired, “can not get warm”, nausea, “feels warm”.
A: Aggravating: Does anything make your symptoms worse?
R: Relieving Factors: Does anything make your symptoms better?
T: Treatments: Motrin and Tylenol for ha without relief and caused
nausea. Have you used any other OTC or prescription medications
for your symptoms?
S: Severity: unable to go to school today.
Develop 3 differentials based on an EBP resource for primary care providers
or your textbook.
Give a one sentence definition of the pathophysiology (cite your reference)
The common S & S
Document this patient’s current S & S for each differential
• Influenza (ICD9 : 487.1)- a viral respiratory illness affecting the upper respiratory
tract and lungs (Reference). S & S: Sudden onset of fever, ha, body aches,
fatigue, cough sore throat, & nasal discharge (Hart, 2015).
• 2. Acute nasopharyngitis ( ICD 9: 460): The common cold, or upper respiratory
tract infection, usually is caused by one of several respiratory viruses, most
commonly rhinovirus (Reference). These viruses, which concentrate in nasal
secretions, are easily transmitted through sneezing, coughing, or nose blowing. S
& S: of the common cold include fever, cough, rhinorrhea, nasal congestion,
sore throat, headache, and myalgia (Dunphy et al, 2011).
• 3. Infectious Mononucleosis (ICD (: 075): Epstein-Barr virus (EBV) infections are
often asymptomatic, some patients present with the clinical syndrome of
infectious mononucleosis (IM) (Reference). The syndrome most commonly
occurs between 15 and 24 years of age. It should be suspected in patients
presenting with sore throat, fever, tonsillar enlargement, fatigue,
lymphadenopathy, pharyngeal inflammation, and palatal petecchiae (Dunphy et
al, 2011)
, ROS
General constitutional systems : fever (-), chills (+), fatigability (+),
night sweats (-), weight loss/gain(-)
• Eyes: Denies Change in vision , blurring, acuity, diplopia,
photophobia, pain, redness, discharge, loss of vision.
• Ears, nose, mouth, sinuses: Allergy symptoms (-), congestion (-),
pain (-), discharge(+), change in hearing(-), tinnitus (-), sense of
smell (-), epistaxis (-), sore throat (+), hoarseness (-), change in
taste (-).
• Chest/lungs: Dyspnea, cyanosis (-), wheezing (-), cough (+), sputum
(-), hemoptysis (-), chest pain related to breathing (-), exposure to TB.
• Cardiovascular : Denies Chest pain, palpitations, dyspnea,
orthopnea, paroxysmal nocturnal dyspnea, edema, claudication.
• Musculoskeletal : Denies Joint pain, stiffness, restriction of motion,
redness, warmth, deformity, leg pain (+).
• Lymph nodes: Denies Swelling, tenderness, drainage
For Julia you would want to assess
HEENT, cardiac, respiratory, abdominal, lymphatic systems
List which body system you want to examine and include a brief statement of any
specialized testing you would want to pay special attention to based on the diagnosis.
LAB TEST TO BE ORDERED AND WHY
• Influenza: Rapid Influenza Diagnostic Testing (RIDT). Identifies the presence of
influenza A and B viruses in nasopharyngeal specimens (Hart, 2015).
• Acute nasopharyngitis : none (Dunphy et al, 2011)
• Mono: Heterophile antibody test. This quick screening test detects a type of
antibody (heterophil antibody) that forms during certain infections. A sample of
blood is placed on a microscope slide and mixed with other substances. If
heterophil antibodies are present, the blood clumps (agglutinates). This result
usually indicates a mono infection. Monospot testing can usually detect
antibodies 2 to 9 weeks after a person is infected. (Reference)
• S: Subjective
• Chief Complaint (CC): cold symptoms x 2 days, worsening.
• History of present illness (HPI): O: I started to have cold symptoms yesterday,
L & D: no information provided. C: included runny nose, watery eyes, cough and
a headache. Was very tired last night and went to bed early. Julia felt even worse
, this afternoon: throat really hurts, very tired, legs ache feels cold, and can’t get
warm. Julia did not go to school today and did not check her temperature. A: no
information provided. R & T: Took Tylenol and Motrin for the headache, did not
help, and has felt nauseous since she took the last dose of Motrin three hours
ago. S: no information provided.
• A: ASSESSMENT: Influenza Type A (ICD 10 code J09) : influenza due to certain
identified influenza viruses.
• Influenza is difficult to diagnose based on symptoms, lab results are important
(Hart, 2015). Julia has a positive RIDT for type A flu, which is 90-95% specific
(Hart, 2015).
P: PLAN
1. Medications
Rx: Oseltamivir 75 mg
Sig: 1 tab po q 12 hours x 5 days. Disp #10 tabs, no refills. (Hart, 2015; Epocrates, 2015)
Early antiviral treatment, symptoms <48 hours, can shorten symptom duration and may reduce
complications (Hart, 2015).
Encourage patients to take OTC medications for cough, fever, pain and muscle aches (Dunphy
et al, 2011; Hart, 2015).
• Ibuprofen 600 mg po q 6-8 hours as needed for pain and/or fever, max of 2400 mg/day
(Hart, 2015; Epocrates, 2015)
• Dextromethorphan 60 mg po q 12 hours as needed for cough, max of 120 mg/day. (Hart,
2015; Epocrates, 2015)
• (Influenza vaccine when better (Dunphy et al, 2011; Hart, 2015).
2. Additional diagnostic tests: additional testing needed only with severe symptoms as listed
below (Hart, 2015)
• 3. Education:
• Cover your cough. The flu is spread through sneezing, coughing and respiratory
secretions (Hart, 2015).
• Flu symptoms typically last for 3-7days and get better without treatment in 5-10
days (Hart, 2015).
• Rest and drink at least 8 eight ounce glasses of fluid each day (Dunphy et al,
2011).
• Call office or return to clinic if symptoms become severe (fever, chest pain, SOB,
worsening cough, increased mucus production) (Hart, 2015).
• Unvaccinated family members should be vaccinated, can receive flu prophylaxis
at same time (Dunphy et al, 2011).
, • Referrals None at this time only needed with severe or progressive symptoms as listed
above (Hart, 2015)
• 5. Follow up. None necessary if getting progressively better (Dunphy et al, 2011). Call
office or return to clinic if symptoms become severe as listed above (Hart, 2015). Follow
up with PCP for RHM.
Meet the Smith Family
Smith Family:
Mary: 44 mother; Patrick: 42 father, Michael: 9 son; MaryKate: 7 daughter; Paddy: 4 son;
Tommy: 4 son (fraternal twins). Also living with the family are Mary’s parents, Katie and John
Foley. Katie age 65 and John age 75.
Clinic setting: large urban city family practice clinic which employs physicians and nurse
practitioners.
Part 1
Today is a busy Monday in your family practice clinic. Your first patients of the morning are a
mother and daughter who are both clients of the clinic. The entire family has been coming to the
clinic for years. You review the chart before entering the room to familiarize yourself with these
patients. Both present today with complaints of pink eye.
When you enter the room you note a Caucasian woman who appears to be about 40 years old.
She is well groomed and appropriately dressed for the weather. There is a young girl standing
near her mother reading the eye chart out loud to her mother. The girl is dressed in clean clothes
and appears well groomed. Both smile in response to your greeting. You introduce yourself and
state you are the nurse practitioner who will see them today for their visit. You begin your
interaction as always by asking what brings them in today for the visit. Mom states “MaryKate
has had a red eye for two days now. It started in her left eye and then I noticed it spread to her
right eye this morning. She’s been complaining of it itching and burning. This morning I had to
all this goop in my eye when I woke up and I noticed my eye looks red too. My four year old
twins always have pink eye at their preschool so we came in to be checked. “
HPI: Mom describes herself and MaryKate as healthy. No recent illness for herself but states
MaryKate is “getting over a cold” that last about a week, runny nose and nasal and seems to be
improving. Was given some OTC cold medications for congestion which seemed to help. She
did not miss school because she did not have a fever.
No one else has been sick at home.
PMH
Mary: denied past illness or injuries. Hospitalized x 2 for childbirth, no surgeries. NKDA. Drinks
alcohol socially, denies tobacco or illicit drug use. Sleeps 6-7 hours/night. No current
medications. Takes a daily multivitamin and a B complex supplement.
MaryKate: no past illnesses or surgeries. Up to date on vaccinations per the medical record.
Social
