Running head: CASE PRESNTATION 2
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Case Presentation 2
N700
Primary Health of the Family
Stella Mbah
Coppin State University
Helen Fuld School of Nursing
March 25, 2014.
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CASE PRESNTATION 2
Case Presentation # 2
Demographic Data
S.A. is a 66 year old Caucasian female.
History of Present Illness (HPI)
S.A. is a 66 year old Caucasian female who present with complain of pain and stiffness in
the neck, low back and bilaterally hips that occasionally disturb her sleep. Patient had a pain
level of 5 out of 10 on the back and hips joints. Pain sometimes disturbs the patient from
carrying out daily activities of daily living. Patient also complained of discovering a cyst on her
left upper back.
Objective Data
GEN: No fevers fatigue, malaise, weight loss or weight gain, night sweat, dizziness.
Eyes: no visual changes, increased tearing, itching, blurry vision.
Head: no trauma, headaches, hair loss or dandruff.
ENT: no running nose, nose bleeds, sneezing, nasal or sinus congestion, sore throat, no tinnitus,
decreased hearing, no throat pain or difficulty swallowing.
Neck: no palpable lymph nodes, stiffness, neck pain.
Resp: no wheezing, chest pain, cough, hemoptysis, shortness of breath. Clear lung sounds.
Cardiac: Patient denies chest pain, shortness of breath at rest or with exertion, no leg swelling.
GI: no nausea, vomiting, heart burn, reflux, abdominal pain, changes in bowel habit, melena,
diarrhea, constipation, hemorrhoids, bright red blood per rectum.
GU: no incontinence, nocturia, polyuria, hesitancy, frequency, dysuria, hemauria, urethra
discharge, erectile dysfunction or low libido.
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CASE PRESNTATION 2
Heme: no swollen glands or lymphadenopathy, no easy bruising or bleeding.
Derm: no new rashes, itching, skin color changes, changes in existing moles, new hair loss or
growth patterns, + cyst 1cm by 1cm of the patient’s left upper back.
Psych: +sleep problems, feelings of sadness, feelings of guilt, concentration, anhedonia, no
suicidal and homicidal thoughts, no changes in appetite, anxiety.
M/S: no myalgia, arthralgia, +stiffness in joints, swelling in joints, cramps in muscles, +
weakness.
Neuro: no headaches, paresthesias, seizures, tremors, shakes, memory problem, numbness,
changes in sensation or strength.
Endo: No polydipsia, polyuria, weight loss or gain, changes in appetite, heat or cold intolerance.
Past Medical History
COPD status post intubation, chronic back pain, and persistent tobacco use.
Social History
Every day smoker, smokes half a pack a day, unemployed, no significant alcohol use, no
drug use.
Family History
+ diabetes in mother
Allergies
No known allergies
Medications
Escitalopram 20mg oral tablet, one pill by mouth daily; guaifenesin 600mg oral tablet,
extended release, one tablet twice daily; lisinopril 2.5mg, one tablet daily; metoprolol tartrate
25mg oral tablet, 0.5 tablet twice daily; pravastatin 20mg tablet, one tablet at night; proventil
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CASE PRESNTATION 2
HFA 90mcg/inh inhalation aerosol, 2 puffs every 4-6 hours as needed; trazadone 50mg oral
tablet, one tablet at night.
Vitals: Temp. 97.8F, wt. 182 lb, ht. 65in, BP: 110/80, Pulse 84, BMI 30.4
Physical Examination
VS 138/80, temp 98.1, pulse 88, res. 17 Sat. 97%, weight 166 lb. General: WNL;
HEENT: WNL, Lungs: clear bilaterally, decreased breath sounds. Heart: RRR S1 S2 without
murmurs, thrills, rubs. Chest wall: WNL. Abdomen: WNL, normal bowel sounds. Extremities:
good blood circulation. Normal pulses.
Assessment
Obstructive Chronic bronchitis without exacerbation (491.20); Major depressive affective
disorder recurrent episode severe degree without psychotic behavior (296.330; personal history
of tobacco use (V15.82); other specified disorders of skin (709.8); osteoarthrosis generalized
involving multiple sites (715.09).
Plan of Care
Prescribed Symbicort 160 mcg-4.5 mcg/inh inhalation aerosol, 2 puffs twice daily
Prescribed Spiriva 18mcg inhalation capsule, one cap inhaled daily
Prescription for Proventil HFA 90mcg/inh inhalation aerosol, 2 puffs every 4-6 hours as needed.
Started on Norco 5mg-325 mg oral tablet, one tablet daily; meloxicam 15 oral tablet, one tablet
daily.
Patient will continue on symbicort, and spiriva. Add albuterol as needed for dyspnea and
wheezing. Patient will continue on antidepressant, mood is stable, Stop smoking cessation
counseling given extensively. Patient was offered patch which she declined; she was also offered
Frankling Square Hospital program to quit smoking. Patient has a cyst in the upper back to the
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CASE PRESNTATION 2
left she would like to be removed. Referral given to see an Oncologist. Patients had x-ray which
confirmed DJD in multiple joints. Patient is on meloxicam which helps, norco added to her
regime for break through pain. Continue daily NSAID. Follow up in one month for physical
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CASE PRESNTATION 2
References
Buttaro, T., Trybulski, J., Polgar, B., Sandberg-Cook, J. (2013). Primary Care:
A Collaborative Approach (4th edition). St. Louis: Mosby, Inc.
McCance, K. L., Huether, S. E., Brashers, V. L., Rote, N. S. (2010). Pathophysiology: The
biologic basis for diseases in adults and children (6th ed.). Maryland Heights, Missouri:
Mosby Inc.