UIT 3 CASE STUDY
10624Instructions
Review the following case study.
In a Word file construct a subjective data set for the case from the information provided.
Structure the subjective data set in the format provided in your lecture materials.
Submit the Word file containing your subjective data set into Canvas.
NU610 Unit 3 Case Study
A 36-year-old female with a medical history of Multiple Sclerosis (MS) complains of constantly feeling
tired even after a period of rest or sleep. She was diagnosed with MS 3 years ago and has been on
Interferon. As a wife and mother of 2 with a full-time job, she states that by the end of the day, she has
no energy whatsoever. The patient explains that she began noticing her lack of energy and tiredness a
few months back, but it has gotten progressively worse. She also mentions that she has missed several
days at work over the last 4 weeks because after getting showered and dressed, she had no energy left
to go to work. Reports occasional glass of wine on the weekends, denies tobacco or illicit drug use. She
has tried some CBD oil to help with energy without relief. Reports sleeping more than eight hours a
night while needing several naps throughout the day. She reports an uncomfortable buzzing sensation
traveling from the neck to the spine with what sounds like a Lhermitte’s sign. She denies loss of bowel
or bladder. She denies fever, chills, weight loss, or weight gain. She reports some nasal congestion but
contributes to allergies which she takes cetirizine 10 mg PO daily. Reports she is up to date on her pap
smear. She does a monthly self-breast exam, which she denies concerns about. She saw her dentist and
eye doctor within the last year and has no issues or concerns. Reports her mother, who is alive, has
diabetes and hypertension. Her father and siblings are also alive without any health issues. She has an
aunt on her mother’s side who also had MS and currently uses a wheelchair. She is alert and oriented to
person, place, time, and situation. Does not appear in acute distress, is well-developed, and is slightly
obese in the abdominal section. Skin is dry, warm, and intact. Normocephalic, neck supple, no
thyromegaly. PERRLA is about 4mm pupil size. Conjunctivae rim pale. Optic fundi examined revealed a
uniform red to pink color; the disk is pale pink, vessels emanate from the optic cup, and the fovea was
slightly darker. Retinal vessels are free from hemorrhages or exudates. Face symmetrical. No
lymphadenopathy. The oral mucosa is pink and moist. Heart rate bradycardic at 56 beats per minute
but regular without pauses or extra beats. Lungs diminished bilaterally but otherwise clear. Abdomen
soft, non-distended, bowel sounds normoactive in all four quadrants. No suprapubic or CVA tenderness.
Able to differentiate between light and deep tough, no dysmetria or ataxia, normal alternating hand
movements, gait steady. Muscle tone inspected and palpated, free from fasciculation, tenderness, or
atrophy. Strength 5/5 in all extremities.
REFERENCES:
LECTURE-
Integumentary
The skin is our largest organ. The average adult has approximately 20 square feet of surface area to provide protection from outside stressors and adapt to environmental situations such as heat and cold.
The skin has two layers: the dermis and the epidermis. The epidermis is the thin, tough outer layer. It is our first line of defense. The dermis, made mostly of collagen, provides elasticity and assists the dermis in resisting tears or injuries.
Hair was once a necessary tool for humans, providing protection from cold, heat, or trauma. Many cultures believe hair is necessary or preferred as part of psychological and cosmetic values. Hair is threads of keratin that grow in cycles. Each hair has a different rest/grow cycle so that certain hairs are always growing while others are dormant.
Integumentary
Subjective Data
Ask about previous skin conditions or problems. What was the problem? When did it happen? How long did you have the skin problem? How was it treated? Was the treatment successful? Has it recurred? Do you have any known environmental or medical allergies? Are there any lesions that you are concerned about today?
Have you noticed any changes in your skin color? How about changes in moles? Include itching, bleeding, or change in color or size. When did this start? Do you have sores that will not heal?
Objective Data
Physical Exam
You should integrate the skin exam throughout the physical exam process, instead of making it a separate part. Lift and open clothing that cover parts of skin to thoroughly examine the skin. Remove shoes and socks to inspect the feet, check pulses, and evaluate nail bed and sensation as the last part of the examination.
Inspection and Palpation
Note the skin tone, color, and lesions. This would include moles, birthmarks, and freckles. Moles may be tan to dark brown in color, and flat or raised. Birthmarks are tan to brown in color, appear flat, and may be irregular in shape. Freckles are brown, flat macules that are found on sun-exposed skin.
The ABCDE danger signs of skin lesions should be kept in mind during the examination.
Asymmetry of a pigmented lesion (not round or oval)
Border irregularity (look for raised borders, notching, scalloping, ragged edges, and poorly defined or blurred margins)
Color variation (tan, black, brown, blue, red, white, or combination of colors)
Diameter of 6 millimeters or more (the size of the end of a pencil eraser)
Elevation and enlargement (change in size; new nevi or lesion; new itching, burning, or bleeding)
HEENT
The aspects of inspection to include will be important while covering this week’s material. Correct use of the otoscope is critical when it comes to visualization of the ear canal and the tympanic membrane in all ages. Visualization also allows the nurse practitioner to conduct an HEENT assessment to determine the presence of redness, lesions, swelling, drainage, or exudate. Palpation is important when assessing the lymph nodes located in the HEENT area.
Subjective:
Start with chief complaint and from there and work your way to the general history.
What is the chief complaint? Headache? Dizziness or syncope? Pain? Blurred vision? Adenopathy?
Ask the usual questions about the chief complaint: Onset, duration, exacerbating factors, alleviating factors, associated signs and symptoms, and quantity and quality of symptoms.
Is there a history of trauma? Was there a workup at that time?
Does the medical history include malignancy of any kind, especially one in the HEENT area? When, where, and how was it treated, how was it resolved, how long ago did it happen?
Any previous strokes or transient ischemic attacks (TIAs)? Any history of surgeries specific to the head, face, or neck? Evaluate family history. Note any history of stroke, TIAs, headaches such as migraines, or even thyroid disorders.
Eye Assessment Tips:
Test visual acuity, visual fields:
Snellen eye chart
Near vision
Confrontation test
Visual field check appropriate for developmental age
Inspect extraocular muscle function:
Corneal light reflex
Cover test
Diagnostic positions test
Inspect external eye structures:
General
Eyebrows
Eyelids and lashes
Eyeball alignment
Conjunctiva and sclera
Lacrimal apparatus
Inspect anterior eyeball structures:
Cornea and lens
Iris and pupil
Size, shape, and equality
Pupillary light reflex
Accommodation
Inspect the ocular fundus:
Optic disc ration (color, shape, margins, cup-disc ratio)
Retinal vessels (number, color, artery-vein ratio [A-V ratio], caliber, arteriovenous crossings, tortuosity, pulsations)
General background (color, integrity)
Macula
Ear Assessment Tips:
Inspect the external ear:
Size and shape of auricle
Position and alignment on head
Skin condition: any lumps, bumps, lesions, and discoloring
Movement of auricle and tragus: any tenderness
External auditory meatus: size, edema, erythema, discharge, cerumen, lesions, or foreign bodies
Conduct an Otoscopic exam:
External canal
Cerumen present: any discharge, foreign bodies, or lesions
Erythema or edema of the canal wall
Inspect the tympanic membrane:
Color and characteristics: scarring or color changes, dull or shiny, opaque or translucent
Position: distended, flat, or retracted, intact or perforated
Test hearing acuity:
Response by patient during conversation
Whisper test
Weber and Rinne tests
Here are some assessment tips for the head, face, and neck:
Inspect and palpate the skull:
Note the shape and size.
Do you find anything out of place, such as lumps, bumps, or discomfort?
Check the temporal arteries and the temporomandibular joint.
Inspect the face:
Look at the facial expressions—any drooping or other abnormalities?
Evaluate cranial nerve VII.
Note any involuntary movements, such as tremors or ticks, edema, and lesions.
Inspect and palpate the neck:
Check the active ROM of the neck.
Evaluate the lymph nodes, salivary glands, and the thyroid gland.
If the thyroid is enlarged, auscultate for a bruit.
Nose, Mouth, and Throat Assessment Tips:
Nose:
Inspect the external nose for any deformity, lesions, and symmetry.
Palpate and assess nostril patency.
Inspect the nostrils using nasal speculum:
Note the color and substance of nasal mucosa.
Note the septum for perforations, bleeding, or deviation.
Evaluate the turbinates for color, drainage or exudates, edema, or polyps.
Palpate the sinus areas for any discomfort or fullness.
Mouth and throat:
Inspect lips, teeth, gums, tongue, buccal mucosa for color, lesions, and proper alignment and structure.
Note motility, integrity, and color of the uvula and palate.
Inspect and grade tonsils.
Inspect posterior pharyngeal wall for color, lesions, or exudates.
Palpate in the neonate for sucking reflex and to confirm palate is intact.
Examining the Nose, Mouth, and Throat:
The nose should be symmetrical in shape, in the midline of the face, and proportional to other facial features. Inspect for any asymmetry, deformity, inflammation, or lesions. Palpate gently for any discomfort or abnormality if an injury is reported or suspected. Test nasal patency by asking the patient to close their eyes while you occlude one nostril and ask them to sniff gently. Then, repeat for the other nostril. Cranial nerve I, olfactory, will be discussed in the neurological module. However, routine olfactory testing is not conducted.
The throat should be inspected for presence of tonsils. The tonsils should be graded as follows:
1+ visible
2+ halfway between tonsillar pillars and uvula
3+ touching the uvula
4+ touching each other
It is common to see 1+ or 2+ tonsils in healthy children and adults. Children have enlarged lymphoid tissue until they reach puberty.
Thorax and Lungs
Respiratory system abnormalities are one of the primary complaints for pediatric and adult patients alike. This week, we will review the thorax and lungs (respiratory system).
Major Anterior Landmarks:
Landmarks are used to identify the underlying structures. The major anterior landmarks are listed here.
The suprasternal notch is found at the top of the sternum.
The sternum, also known as the breastbone in lay terminology, consists of the manubrium, the body, and the xyphoid process.
The manubrium is the upper part of the sternum, which articulates with the clavicles, the first rib, and part of the second cartilage.
The manubriosternal angle, or angle of Louis, is a logical place to start counting ribs. The angle of Louis marks the end of the manubrium and the beginning of the body of the sternum. It is also the location of the second rib. Palpate the angle of Louis; move over to the second rib and down to the second intercostal space and then onto the third rib, and so forth. The intercostal cartilages connect the ribs to the sternum, as noted above. The ribs can be counted down to the tenth rib via the intercostal spaces.
The costal angle is the point at which the right and left costal margins form an angle of 90 degrees or less. The degree of angle is larger when the rib cage is overinflated. This is a common finding in patients with COPD.
HPI Important Points:
When was the patient’s last chest X-ray, tuberculin skin test, exposure to irritants in the workplace (including dust, pollen, mold, asbestos, strong perfumes, etc.)? Always assess tuberculosis (TB) risk, even in children.
Environmental concerns should include the home and the workplace. Does the patient wear a mask to prevent inhalation of toxic or irritating substances? Is there a quality assurance plan in place to evaluate for exposure levels? Does the patient have an annual exam with pulmonary testing such as pulmonary function tests (PFTs) or chest X-rays?
Confirm the current medication list. Certain medications have a side effect of cough such as ACE inhibitors.
Does the patient smoke? Ask specifically about cigars, smokeless tobacco, and electronic cigarettes, as well as herbal products. If this is a child over ten years of age, ask the child if he or she smokes. For all patients but especially children, question them about exposure to secondhand smoke in the home or primary environment. Ask parents about smoking and smoke exposure. Is there a previous history of asthma or other upper respiratory issues?
Do you have any chest pain with breathing? Ask the patient to point to the area that hurts. Is it with a deep breath, a shallow breath, or both? Is the chest pain constant or intermittent? Ask the patient to describe the pain.
Ask about history of respiratory issues, including family history of asthma, cancer, TB, recurrent pneumonia, bronchitis, or emphysema.
Ask about vaccinations: Are all vaccinations up to date? This is important for children and the elderly. Always refer to the most current immunization schedule.
Examination of the Respiratory System
When conducting an exam of the respiratory system, remember to start posterior then move anterior. Move from side to side during the exam (left to right then back to left on the next line), not up and down. The exam you do on the posterior thorax must be repeated on the anterior thorax.
A summary of the respiratory system exam includes the following:
Inspect:
Thoracic cage
Respiration: quality, quantity, effort, depth, use of accessory muscles, or abdominal effort
Skin color and condition
Patient’s choice of position
Facial expression
Level of consciousness
Palpate:
Symmetric expansion
Tactile fremitus
Lumps, masses, and tenderness
Percuss:
Overall lung fields
Diaphragmatic excursion
Auscultate:
For normal breath sounds
For whether there are any abnormal or adventitious breath sounds
Bickley, L.S. (2021). Overview: Physical examination and history taking. Bates’ guide to physical examination and history-taking, 13th ed. New York: Lippincott, Williams, & Wilkins. ISN-13:9781496398178
Chapter 10 – Skin, Hair, and Nails
Chapter 11 – The Head and Neck
Chapter 12 – Eyes
Chapter 13 – Ears and Nose
Chapter 14 – Throat and Oral Cavity
Chapter 15 – The Thorax and Lungs
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