Case Study #2
GERO CASE STUDY - Fall 2011
Use the following template to complete your answers to this case study and
resubmit via tigermail on or before the due date.
SCENARIO
Amy Michaels is a 65-year old widowed Asian female, first visit, requesting a physical
exam for the Foster Grandparents Program. Ann has not seen a family physician since
she went through natural menopause 17 years ago. She requested an appointment
during the day because of difficulty driving at night, but is otherwise enjoying "good
health."
TENTATIVE DIAGNOSES
Based on the information provided so far, what are the potential diagnoses?
Diagnosis not applicable at this time - well visit.
HISTORY
Below is the history obtained from Ann. What are the significant findings that will help
you narrow down to a specific diagnosis for Ann? Significant findings highlighted
Requested Data
Allergies
Medications
Childhood diseases
Immunizations
Surgery/transfusions
Hospitalizations
Fractures, accidences, injuries
Adult illness
OB/GYN history
LMP
Las pelvic/PAP
Mammogram/SBE
Gravida/para
Last complete PE
Last eye exam
Last dental exam
Family history
Data Answer
None
Tylenol/Advil prn headache and arthritic pain;
multivitamin with iron; infrequent Maalox
Chicken pox, measles, mumps
Unknown for childhood illness and tetanus. Has not
received influenza, pneumococcal, or hepatitis B
vaccines.
Appendectomy 25 years ago. None
Vaginal delivery w/o complications x 2 - 1955, 1959.
Mild cervical neck strain from MVA 1987 (seen at
Urgent Care, no further problems
Pneumonia, 1977; infrequent colds
1980
1979 or 1980
Never/never
G2 P 2 A o
Probably last pregnancy
4 years ago; began wearing bifocals at age 47; sees
halos around lights at night
3 years ago; has all natural teeth
Parents died 30 years ago in MVA; not aware of prior
illness
Maternal grandmother; 98 y/o; "healthy" but has
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Social Habits
Social groups
Relationship with family
Physical activity and functional
status at home
Insurance/income
Home
Appetite, 24-hour diet recall
Sleeping pattern
How do you handle stress?
How would you rate your life on
scale from 1 to 10 (10 best)?
cataracts & arthritis
1 living brother; 56 y/o; hypertension
3 living sisters; 59 y/o, 61 y/o, 63 y/o; 1 w/ CAD & 1
w/ hypertension
2 healthy children; 42 & 38 y/o men, good health
Nonsmoker, occasional social drink, drinks 1 cup of
coffee & 1 cup of tea per day, no recreational drugs,
walks several miles a day during nice weather and
maintains her flower & vegetable gardens
Church choir; anticipating Foster Grandparents
Program
Assists maternal grandmother w/ shopping, lunch
together weekly, siblings are supportive and
interactive when possible, but "very busy" with own
families; sons very protective since death of their
father, assist mother with house-hold chores,
grandchildren visit at least weekly with sons
Able to care for self; shops, cleans, performs all
ADLs. Sons help with home repair and maintenance.
Still able to drive own car, although does not like to
drive at night anymore.
Medical and dental insurance through AARP and
Medicare; income through husband's pension and
Social Security benefits.
Owns her own home, ranch style w/ basement, lives
within five miles of both sons.
B: Juice, toast, grapefruit or cereal with 2% mild,
coffee
L: Soup and crackers or grilled cheese sandwich,
fresh or canned fruit, 2% milk
D: Tea, baked potato with cheese, peas, cake
S: Yogurt
Sleeps 11/11:30 to 7/7:30. Usually up x 1 to void.
Rating 3. Handles stress by increasing activities and
talking with friends and family.
REVIEW OF SYMPTOMS
Below are key points of ROS
SYSTEM REVIEWED
General
GI
GU
DATA ANSWER
No acute distress
Denies black, tarry, or bloody stools or
emesis. No constipation.
Denies problems with urinating, burning,
frequency, or emptying her bladder.
2
Lungs
Cardiac
Denies SOB, cough.
Denies sweating radiation of pain to arm or
neck. No SOB or palpitations
PHYSICAL EXAM
Significant portions of PE based on Ann's complaints
SYSTEM
Vital signs
General appearance
Skin
HEENT
Cardiopulmonary
Abdomen
Breasts
FINDINGS
T = 97.6 (o), P = 80 and reg, R = 12 easy,
B/P 160/92, RA sitting and standing,
158/90 LA sitting, Height 64 1/2", Weight
125 lbs.
Well-nourished white female. Appears her
stated age. Alert, oriented, affect
appropriate.
Warm and dry; no jaundice, bruises,
ulcerations, rash. Negative for clubbing or
cyanosis
Normocephalic; normal hair distribution,
PERRLA, sclera clear, conjunctiva pale,
fundoscopic-bilateral lens opacification,
red reflex present, unable to visualize
retinal details, EOMS intact; Visual acuity
20/40 OS 20/60 OD with corrective lenses,
TMs and canals clear, Weber lateralizes
appropriately, Rinne AC > BC; nares
patent, turbinates sl. pale and edematous;
oropharynx clear, mucous membranes
pink and moist, no ulcerations noted,
tongue symmetrical, uvula midline;
negative sinus tenderness; neck supple,
neg. adenopathy, tenderness,
thyromegaly, bruits, JVD.
Cardiac: No chest wall abnormalities; neg.
thrills, PMI at 6th intercostal space 1 cm to
left of MCL; reg. rhythm w/ occas. extra
systoles, S1, S2 (accentuated) w/ soft S4.
Grade II/VI systolic ejection murmur at left
sternal border.
Lungs: Diaphragmatic excursion WNL,
CTA, and percussion
SI. rounded, striae present, BS x 4 quads,
tympany throughout, soft, nontender, neg.
mass or organomegaly, CVA tenderness
Symmetrical, neg. dimpling, nontender, 1
cm mobile, firm nodule left breast in 6
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Genitourinary
Orthopedic
Neurological
o'clock position inferior to areola, neg.
axillary or supraclavicular adenopathy or
nipple discharge
External genitalia w/o lesions, ulceration,
or discharge. Vaginal vault neg.
discharge, ulceration, min. erythema w/ sl.
dry mucosa, cervix mild inflammation, PAP
smear obtained with brush and spatula;
neg. pain w/ cervical motion, adnexal
mass or tenderness; uterus retroflexed
approx. 8 weeks in size. Rectal: Good
sphincter tone
ROM w/o pain or limitation of movement;
neg. erythema, edema, pain w/ palpation;
click present right knee; peripheral pulses
2+ bilateral; cap. refill brisk
CN II-XII intact, DTRs 2+ bilateral upper &
lower extremities; no tremors noted; gait
normal; Romberg neg; flexion & extension
strength equal bilateral; discrimination of
pain intact
DIFFERENTIAL DIAGNOSES
Provide the significant positive and negative data that support or refute your diagnoses
for Ann.
DIAGNOSIS
HTN
Decreased visual acuity possible glaucoma
Breast nodule
Osteoporosis
POSITIVE DATA
BP 160/92, age, family
history, vision changes
Difficulty driving at night
Sees halos, wears bifocals,
bilateral lens opacification,
20/40 OS, 20/60 OD with
corrective lenses, age
1 cm mobile, firm nodule
left breast, female, age,
Asian female, age, small
body frame, arthritic pain,
menopause, no prior
hormone replacements, no
calcium supplements
Deficient GYN maintenance Last pelvic/PAP 1980,
SBE/mammogram never
Deficient immunization
Unknown tetanus, has not
received influenza,
NEGATIVE DATA
normal BMI (21.5),
nonsmoker
PERRLA, Sclera clear, no
eye pain. No history of
prolonged corticosteroid
use, no family history
Normal BMI, no family
history, no HRT, no
excessive alcohol intake
Nonsmoker, not excessive
alcohol intake, not on
thyroid replacement
therapy, no corticosteroid
therapy, no renal disease
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pneumococcal or hepatitis
B vaccines
DIAGNOSTIC TESTS
Based on the history and PE the following diagnostic tests were ordered. The test and
results are provided. You will need to provide a rationale to support the use of the test
for Ann or provide documentation why you would not order this diagnostic test in this
case.
DIAGNOSTIC TEST
PPD skin test
RESULTS
+ skin test, 10 cm
induration
U/A; CBC, electrolytes,
renal panel, liver panel, uric
acid, T4, TSH, nonfast,
cholesterol & HDL
Cholesterol 247, HDL 32,
otherwise WNL
Mammogram
Benign calcification lt.
breast, Recommend annual
mammogram
Fecal occult blood testing
Negative hemoccult
EKG
EKG WNL
Chest radiograph
CXR essentially normal
with few scattered fibrotic
RATIONALE
PPD to test for tuberculosis,
has no S/S but may be a
requirement for the Foster
Grandparent program
Pt has HTN, need baseline
labs to monitor for organ
damage. UA to check for
infections, proteinuria,
glucose, ketones
CBC to screen for anemias,
infections
Electrolytes to screen for
diabetes.
Renal panel for kidney
disease screening
Liver panel to screen for
liver disease
Uric acid for gout ( would
not order this test, has no
S/S of gout)
T4/TSH screening for
thyroid disorders
Cholesterol and HDL to
screen for lipid disorders
Screening for breast
cancer, she has never had
screening mammogram
and needs one annually.
She had a nodule on PE.
Screening for colon cancer,
needs annually for her age
EKG to r/o arrhythmias, she
has HTN and a murmur.
Need baseline.
Had a positive PPD , needs
CXR to r/o active infection.
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changes
Bone densitometry
Bone densitometry shows
risk of fracture for age and
osteopenia
Has HTN, check size of
heart.
Bone density for
osteoporosis screening,
needs every 2 years at her
age
DIAGNOSES
Based on the data provided, what are the appropriate diagnoses for Ann?
List all appropriate diagnoses in priority order. Provide rationale for concluding these
diagnoses are correct?
1. HTN: elevated BP on PE
2. Osteoporosis: bone density shows risk of fracture for age and osteopenia
3. Dyslipidemia: Cholesterol 247, HDL 32 on non-fasting labs- would repeat with a
fasting lipid profile
4. Decreased visual acuity; possible glaucoma: vision changes , halos, lens
opacification
5. Deficient GYN maintenance: no prior SBE/mammogram, no pelvis/PAP since
1980
6. Underimmunization: no influenza, pneumococcal, tetanus, or hepatitis
immunizations
7. Benign breast nodule: benign calcification on mammogram
THERAPEUTIC PLAN
Provide answers with scientific basis for the following questions about Ann's treatment
plan. Provide APA references when indicated.
(1) What influence does Ann's + PPD have on her participation in the Foster
Grandparents program? The CXR was negative so there should be no issues. She
needs to be told to never have another PPD, she will need a CXR in the future. She is
at low risk for TB.
(2) What recommendations can you take for Ann in terms of immunizations?
She needs the flu yearly, the pneumoccal once, zostavax (history of chickenpox), Tdap
(3) What counseling would you do for Ann relative to her health promotion and
prevention needs? Address the areas of:
Diet: due to osteoporosis she needs to eat a regular well-balanced diet. Increase food
sources rich in calcium (dairy products, green leafy vegetables, almonds, tofu and OJ
fortified with calcium), protein ( chicken, lean cuts of beef and pork, fish, legumes), and
vitamin D ( milk, salmon, cereals with added vit D). Limit caffeine intake.
Due to high cholesterol she needs to limit high fat, saturated fat, fried food and fast
food. Eat foods that are baked, broiled, grilled or stir-fried. Eat more fruits and
vegetables. Avoid whole or 2% milk or dairy products. Limit eggs to 2 yolks week. Use
olive,canola or peanut oils.
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Due to hypertension limit the sodium intake to 1,100-3000 mg daily.
Injury prevention: at risk for injuries due to falls. Survey home to look for fall hazards
such as rugs, cords and clutter that she might trip over. Have good lighting (night lights)
at night when she gets up to use the bathroom with a clear path to the bathroom. Install
rails in the bathroom for safety and nonskid pads in the bathtub. Pt has a basement,
make sure there is a railing on the stairs and good lighting.
Dental health: Make her an appointment with her dentist, recommend dental visits
every 6 months
Hormone replacement therapy: Premarin 0.625 mg PO daily
ASA therapy: Risk factors are HTN and dyslipidemia. ASA 81 mg PO QD
Regular health maintenance: Needs PE yearly. Mammogram every year, if PAP is
negative then she will not need to have PAP again due to her age. Bone density every
2 years. Needs referral for colonoscopy since she has never had one, if normal then
every 10 years, if polyps then every 5 years. Flu shot yearly.
(4) What therapy would you order for Ann for her osteoporosis?
Calcium supplement: Os-Cal 500 mg PO 1-3 times daily
Vitamin D: 800 mg PO daily with the calcium
Biphosphate: Fosamax 70 mg PO weekly or Boniva 150 mg PO monthly depending on
pt preference
HRT: Premarin 0.625 mg PO daily
30 minutes of walking at least 3 times a week.
(5) What patient education is appropriate relative to the osteoporosis?
You have osteoporosis and you need to prevent the disease from progressing and take
measures to prevent bone fractures. Use caution when walking on wet, slippery
surfaces. Physical activity is vital to maintain and prevent further bone loss. Weight
bearing activity is the best activity, such as walking. Avoid high impact sports and
activity such as jumping and high impact aerobics to prevent fracturing the bones.
Avoid risk of falls. Do not use throw rugs. Bathtubs should have nonskid protection.
Get vitamin D from 30 minutes of sun exposure daily.
(6) When would you have Ann return for follow up?
I would have her come in to repeat the lipid profile fasting, if cholesterol still elevated
and HDL still low, then suggest TLC (diet and exercise) for 3 months, and then repeat
labs.
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(7) What referrals should be made for Ann?
Gastroenterology for colonoscopy
Ophthalmologist for vision changes, halos around lights, bilateral lens opacification
Gynecologist for uterine enlargement
Schedule appointment with her dentist for exam and cleaning
References
Cash, J. C., & Glass, C. A. (2011). Family practice guidelines (2nd ed.). New York, NY:
Springer Publishing Company.
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary care: the
art and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F.A. Davis
Company.
Goolsby, M. J., & Grubbs, L. (2006). Advanced assessment: Interpreting findings and
formulating differential diagnosis. Philadelphia, PA: F.A. Davis Company.
Seller, R. H., & Symons, A. B. (2012). Differential diagnosis of common complaints (6th ed.).
Philadelphia, PA: Elsevier Saunders.
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