OSCE Example

7/31/2019 OSCE Example

1/19

T hom as C hol7/5/11


2/19

Thomas Chol @ 00238569 W ritten Case Study 7/5/11

Subjective /Info rm atio n S ou rce a nd S ta te me nt o f R elia bility: T he d eta ils o f th e s ub jec tiv e p art o f th is ca se stu dy i j)w ere obtained from the patient w ho Is a fa irly re liable historian although at tim es he w as reluctant to-,}~ ) A j ) ldlscfose som e Inform ation, In those cases and also for the recorded dates, h is m edical records w ereutilized. , II? f l 1 J J J f , { U - , I J \\.t Am k.w-- . } t r Y ~ ~ . . . ~ .cc : The p atie nt, M ,H " p re se nts fo r a '< lh er;k up .o f h is s ta ge IV d ec ub itu s p re ss ure u lc er o K' h is rig htb utt oc k ( di ag no sed 3 /4 /1 1) . l~~)H~Wt.l. W~ p t - i s . 'nVt\ ..-~vJ"'tV1" ~ !H PJ: M r. M ,H . is a 81 year old, non-am bulatory C aucas~ an m ale nursing hom e patient w ith a history ofprevious pressure ulcers on the elbow (9/21/10 -1/29/11) and hip (9/21/10 -11/1/10), current " jd ep re ss io n (d ia gn os ed 3 /4 /1 1), o ste oa rth ritis (o ns et d ate n ot a va ila ble ), m an ag ed CHF ( d ia gn os ed r ' ~ v10/19/10), COPD (d iag no se d 2 /1 2/1 1), p ro sta te hv pertrop hy w ith urin e o bstru ctio n (d ia gno sed ' t V , { I1/29/11), and stage II C KD (diagnosed 9/21/10) that presents for a check up of his stage IV decubituspressure ulcer on his right buttock (dIagnosed 2/28/11), H e currently reports no pain In the right.tf! ' buttock . H ow ever he feels m ore com fortable w hen lav.lng supJ~ e In bed w ith extra pillow s under his legs u i~. I~ versus slttlng ln a chair. He strt:s'tt'i:tth~o~Jfs4getifr}g~n?aIl~ t~e last checkup. He reports-J U ) ; l i _ . { fr L ~ ) /~ / - f " no drain~ge, exudate or any unusual odors from the area. H e denies having a fever, sw elling, or feeling ru~~~)

\). .( \ any malaise. The patient denies any lower 11mbmuscle weakness or change In mobility s ince he uses a A G Of Y ) ! - J " ?.;f'__';:.:.w heelchair, H e has been unable to self-am bulate since com ing to the nursing hom e 2 years ago. H e has \JIJ )V '-~. . . .c t : jf' ""~ -been compliant w ith his current treatment plan which consists of c leansing the wound w ith normal. .. '{ () >sa lin e, th e a pp lica tio n o f sllve rc el a ntlm lcrob lal ca lciu m a lg in ate dres sing a nd sle ep in g o n a s pec ia lty ) ILI~y& j J J - - ~y r t e . ; ~ o mattress. P rar.a~ .:M l..-V ~ ~ , ~ v J . < 4 hw.t.v.tt- W~- 0 he. ~~~ /,~ ~ Iyt} ()j5~--l ~ c M ~ V ' ~k i


3/19

Thoma s Cho] @00238569 W ritte n C a se S tu dy 7 / 5 / 1 1

are bo th a live and hea lthy, H e has one son who is 57 yea rs o ld and 3 grandklds. None o f h is survivingfam ily m em be rs h ave C A D, hypertens io n, d iabe tes , o r ca ncer and are genera lly h ea lth y.Medica t ions :

aspirin 81 m g- 1 tablet PO lx daily po tass ium ch lo ride 20 m eq- 2 table ts PO 3x d a ll y furo sem ide 20 m g- 1ab le t PO r x da l ly spirono lactone 25 m g- 1 tablet PO1x daily tam sulo s ln Hel 0.4 m g- 1 capsule PO lx d ally a t b ed tim e fentanyl 50 mcg /h r pa tch - e ve ry 72 h ours lexapro 10 m g- 1 tablet PO 1x da l ly lo ra tld ine 10 m s- 1 tablet PO tx d all y h yd ro co do ne -a ce ta m ln op he n 10mg/SOOmg- 1 tablet PO every 4 hours as needed a lbute ro l 0,083% Inhaler- 1 unit d ose via ae ro so l2x d ally ca lcium a lgina te s liver d ressing- changed every o th e r day no herba l o r a lte rna tive m eds ~ :

A ll erg ie s: T h e p atie nt Is a lJe rg lc to s ulfa d ru gs a nd m o rP hln e()/fid -t2 )1u ; )Vaccina tions : He has never h ad th e influenza vaccine and refuses future vaC Cina tlon~ e lved h is T Ov ac cin at io n o n 12/1/99 and w as vaccina ted fo r pneum onia In 2~08. / q~ROS:Y G enera l: T he pa tient d entes a ny re cent w eigh t ch ange , any ch ange In appetite , s le ep pa tte rns,

pyre xia , ch ills , no cturna l d ia ph ore sis , ge ne ra lize d w ea kne ss. H e re po rts fe eling m o re fa tiguet ha n u su al r ec en tl y./' H ead : T he pa tient denie s any cepha lgla , d izziness, IJgh th e adedne ss o r lo ss o f h a ir,/ E yes : T he pa tient d enies a ny recent ch anges in visua l acuity, pa in, .(~ dnt?ss ,ze ro pth alm la ,

d ip lo pia , b lu rre d v is io n, u nu su al te arin g, ,in cre as ed lig ht s ~n jltl vlty , o r d ifficu lty s ee in g a t n ig ht,T he pa tie nt us es co rre ctlv e le ns es. (M11l/l./ 1//,tfX/ ,

yEars : T he pa tient doe s no t use a hearing a ld . He denie s any d ifficulty h ea ring, tinnitus ,d isch arge , v ertigo , o r e ara ch es .

/ N ose and Sinuses : T he pa tient denies any change In sm ell, conges tion, d isch arge , itch ing,./ epis taxis , o r s inus pressure .

/ M outh : T he pa tie nt d .Je ~.le ~,~ .ny,na rge I,I_)a~ e, too th aches , gum pain, bleed ing gum s, o r th e

u se o f d e ntu re s. j tz.".J/IltJ{J/...J/ b Y ! ; . _ l -~ Th roa t: T he pa tient denies xe ro stom ia , frequent o r re cent so re th ro a t, o r hoarseness.YN eck: T he pa tie nt d enie s a ny lum ps , go lte r, s tiffne ss , o r te nd erne ss.Y C hes t: T he pa tient d ente s any lum ps, nipple d isch arge o r pa in. C ard iac: T he pa tient denles any pa in o r d lscom fo rt, pa lpita tions, edem a, o rthopnea , o r/ paroxysm al nocturna l dyspnea .


4/19

T ho mas C ho l @00238569 Written C ase Study 7/5/11 _ ' "l/ . 1.,, ; / ' - j l q pI f t tA~ I u Y R espirato ry: T he patient denie s any cough , hem optysis , dyspnea, pleurisy, or a ny s pu tum \Jyl.~" f i J ; A j~~p ro ductio n. H e rep orts o ccasio nal sh ortn ess o f brea th a nd w hee zing th at o ccurs a fte r e xe rtlo 'l{ .V /~ {tzV v.../

Gastro inte stinal: H e denies any dysphagia , odynoph agla , nausea , ch ange in bowe l habits , ~ Im ele na , h em ato ch ezla , h em orrh oid s, co nstipa tio n, d Ia rrh ea , em esis , ab do min al pa in, e xcessiv efla tulence, o r jaund ice . H e adm its som e occasiona l h ea rtburn a fte r eating som e spicy food tha ta ll ev ia te s w ith a nta cid s.

U rina ry: T h e patient could no t com ment on the frequency of urinatio n because h e is on acathe te r but he d enie d a ny b urn ing o r pa infu l u rina tio n, o r h em aturia .

Genita l: T he pa tient d enied any te sticu la r pa in, d ischa rge from the penis , o r any m asses. Periphe ra l va scular: T he pa tient denied any leg cram ps, va rico se veins, o r pe riphe ra l ha ir lo ss . M usculo ske leta l: T he pa tient d enied any m uscle pain , sw elling, redness, te nd ern es s, re ce nt J ,r . /.,:

Men ta l S ta tu 's ;> /


5/19

Thoma s Cho l @00238569 Writte n Cas e S t ud y 7 / 5 / 1 1

The patient was oriented to tim e, person, and place, The patient was able to count back wards from 100by r H e w as able to register and recall 3 random objects from short term m em ory and correctlyidentify a pencil and watch. H e was also able to repeat back a chosen phrase.Head: ~_l/\Aih~ ' v " ? '0 ~~ '!kl. h w lY)\..t~ jl.~.ip r --_.- t J V .!A.Pv\r--- 'The patient has a norrnocephallc sk ull w ith no soft or tender areas, The hair w as gray and distributedevenly on the scalp with a not too silk y but not too course texture. There w as no m ale pattern balding.Eyes:T he eyes w ere not red, sunk en or Icteric and the patient did not have ptosis. T he palpebral conjunctivaw as pink . The patient's pupils were round and about equal In size. lid lag was negative. Patient's eyesw ere able to converge to focus on a near object. To avoid any unnecessary discom fort for the patient,the corneal reflex w as not tested, V isual acuity w ith corrective lenses w as m easured at 20/70 w ith theleft eye and 20/100 w ith the right eye. T here w ere no visual fie ld defic its upon confrontation w itheither the left or right eye. T here w as no visual extinction, P eripheral vision w as only slightly decreasedIn both eyes, The patient had no trouble w ith any extraocular m ovem ents. B oth direct and consensualpu pillary ligh t re flexe s w ere prese nt In bo th eye s. . ;Jaf(/p4.J/i1JU;j lj!l4'/(_.)Ears:T he a ur ic le s, p re -a urlc ula r a nd p os t-a uric ula r re gio ns s howe d n o le sio ns , s ca rs , k elo ld s o r a ny d is ch arg e,T here w as no tenderness upon palpatlon, T he tym panic m em brane w as V isualized w Ith the otoscope. Itw as pink , non-perforated and the m alleus could be seen through It .(g@ ~:lerum en w as present and '-Ith ere was n o c alc ific atio n o f th e e ar c an al. T he P


6/19

Thom as Cho l @00238569 Written C ase Study 7 / 5 / 1 1

lower pala te , o r the base o f the tongue. T here was also no cyanosis at the base of the tongue. T heposterio r pharynx as pink with no lesions. T he tonsils were pre sent and no t enlarged , T he T MJ waspalpated and was not tender. T he patient repo rted no change in taste . T he patient was able topro trude the tongue and open the m outh against re sis tance . T o avo id unnecessa ry discom fort fo r thepatient, the gag reflex w as no t te sted ,Neck:T he thyro id w as located centra lly and m oved w ith sw allow ing, It was not enlarged and absent o f anyn od ule s, m a ss es , Of any asym m etry. P alpa tio n of th e thyro id isthm us and lobes whlle s wa llo win g a ndno t sw allow ing elicited no tenderness. P alpation o f th e p re au ric ul ar, p os ta url cu la r, o cc ip ita l, to ns il la r,s ubm an dib ul ar , s ubm en ta l, s up erfic ia l cervical, p oste rio r c erv ica l, a nd s up ra cla vic ula r ly m ph n od ese lic it ed n o t en d er ne ss ,Face:T he patient was able to show his teeth , sm ile , frown, puff h is cheeks, ra ise the eyebrows, and shut thee ye s trgh tly W Ith out a ny difficulty. U gh t touch sensatio n w as Intact in th e o pth alm ic, m axilla ry, a ndm a nd ib ul ar a re as ,Cardiovascular:j No th rills were felt upon palpa tion o r the carotid a rtery unila te ra lly and no bruits were heard uponausculta tlon. Periphera l pulses were taken and were unable to be pa lpa te d in. th e .g "~ r~ il f~ cpgd l s;c.A t A A ~ poplite a l, and posterio r tibia l arte ries . T he rad ia l, brach ia l, and fem oral a rteries ~"~ ;e pa lpable andc v r J > pulses w ere sym m etric w ith a n Intensity ~"271'T he pa tient's capillary refill in th e fingernails w as und er2 see s. T here was no pectus carinatum oqHfctus excavatum . T here w as no parasternal heave pre sent.

C+ t f T he apical im pulse W as attem pted but could not be palpated . T here were no visible o r palpablepulsations in the aortic, pulm onic, m itra l, o r tricuspid areas. T hey w ere also absent In t he e pi ga st ri cv v- area , A ~ ~ j ~ ~ at ~V\rt\ ~ rb~ I

A usculta tion over the ao rtic, pulm onic, ~ itra l, and tricuspid a rea s bo th w i~h thel"hatlent supine andsitting using bo th the bell and the diaph ragm were sim ila r. 51 and 52 were heard in a U a rea s w ith no 53,54, or any systo lic m urm urs, d iasto lic m urm urs, bruits o r frictJon rubs heard In any areas. T he heart beata t a regula r rhythm . The JVP m easurem ent was attem pted but the Internal jugular ve in could no t belo ca te d. C onse que ntly, th e he pato jugular re flex w as no t perfo rm ed ,T here was no pitting edem a found a t the level o f the m id-shaft o f the tibia o r a t the level o f the m edia lm alleo lus. T here w ere no varicose veins, foo t disco lo ration, o r w ounds. T he feet w ere no t significantlywarm er than the o ther extrem ities . C apillary refill a t the toes were w ithin 2 sees. Hom an's sign wasnegative.Respira tory


7/19

Thomas Choi @ 00238569 W ritten Case Study 7/5/11

T he patient w as breathing w ithout the use of any accessory m uscles, T he A P:iatera l ratio w as m easuredto be approxim ateIY t:i~~) C hest expanslon w as symmetrical. P alpatIon of the front of the c he st a ndthe back revealed no areas of tenderness or increased tem perature, The trachea w as positioned In them idline. P ercussIon over all lung fie lds in the front and back revealed a sma ll amo un t o f h yp erre so na nc ethroughout, T here w ere no areas of dullness. V ibrations w ere fe lt symmetrically during tactile vocalfrem itu s In a ll lu ng a re as , Wh is pe re d pectori loquy, eg op ho ny, an d b ron ch op ho ny w ere all ne ga tive ,A uscultation over all lung fie lds in the front and back w ere m ostly vesicular, T here w as a sm all am ountof d lffu~ cex.~~~ ~~~_~~ee:l, noted but no crack les or rhonchi w ere present. The diaphragm aticexcu rs lo 'nwascmeasu re tl t o be about 3 em . .Abdomen:The abdom en w as sym metric, round In contour w ith no caput m edusae, striae, herniation, and novisib le scars, T he um bilicus w as inverted and there w as no visible perista lsis. B ow el sounds w ereauscultated In all four quadrants. N o bruits w ere heard over the abdom inal aorta, left renal, right renal,le ft lila c, a nd rlght lila c arte rie s, A ll ab domina l q ua nd ran ts W ere tym pan ic up on p ercu ssion . T he liverspan was about 10 em at the m ldclavlcular U ne and the liver edge w as not palpable., T he spleen w as notpalpable and there w as no dullness to percussion over T raube's s pa ce . Ligh t a nd de ep p alpa tion ove rthe four quadrants found areas of tenderness, guarding; ,;; ~ny masses . T~e re was n o CVA te nd ern es s,InguInal nodes are not enlarged and no Inguinal hernias w ere noted. N o fullness of flank s was notedand there w as no fluid w ave pre se nt. M cB urn ey 's sign , p soa s sig n, o btu rator sig n, R ovsing s ign , a ndMurp hy 's s ig n were a ll n eg ativ e,Musculoskeletal:

Spine:There w as no kvphosls, lordosls, o r sco liosis, P arav erteb ral m uscle s w ere p alpa ted an d elicite dno pain. F ist percussion of the sacroiliac jo ints could not be perform ed because the patientJ'/v~could not be m oved from a sitting or laying position on the bed, The patient w as able to extend,O M ~ ~ r . f flex, rotate, and laterally bend the neck . H e was able to rotate and laterally bend the spine but' 1 ~ i J L r . ! 6 because he could not be reposltfoned, flexion and extensIon could not be tested.I t Shoulder:S houlders w ere level and symmetrical w ith no scars or lesions. T he epitrochlear and axlllarvnodes were non-tender and not enlarged. There was no tenderness on palpation of theshoulders. H e had full range of m otion in the rotator cuff b ilatera lly,Elbow' I t}~ l& IjThe e l~ov/~J - A ! J t t l t y t l l r n ~ ~ r ~ 1 / t ~ ~ ~ f ~ ~ t J t ~ P ; ; nn palpation, The patient w as able to flex,......e xten d, sup in ate, a nd p ron ate the jo in t fu lly,Wrist:The w rist w as not swollen or red, There w as no paIn on palpation. He w as able to flex, extend,abduct, and adduct the w rist fu lly .

Hand:


8/19

T ho m as C ho l @ 0023 8569 W ritte n C as e S tud y 7 / 5 / 1 1

H eberden 's o r Bouchard 's node s w ere no t pre sent. P a lpa tion o f th e ca rpa l bone s, andcom press ion o f M ep and D JP jo ints d id no t e licit any tenderness. T he left po in te r finge r w asam puta ted a t th e PIP jo int. B esid es th is exception, a ll o th er finge rs and thum bs w ere able toflex, extend , abduct, and adduct fully. T here w as no pro blem In oppo sition fo r th e thum bs anda lso th ere W as no no tice able th ena r a tro ph y. Tlnel's s ign and P ha len 's te st w ere ne ga tive .

H ips :T he re was a surgica l scar no ted In th e a rea over th e le ft a ce tabu la r fo ssa th a t m ea sured about10 cm . T he Ilia c cre st, ilia c tube rcle , A SIS , PS IS , gre ate r tro ch ante r, a nd Is ch ia l tube ro sity w erepa lpa ted and were no t tender. T he s tra igh t leg ra ise te s t wa s re fused by th e pa tien t. T he

J J ) /pa tfent wa s no t able to s tand so th e range o f m otion fo r th e h ips w as lim ited . Howeve r th ef i r ) : ' ! ' patient wa s able to flex, extend , abduct, and adduct h is legs a t leas t to a few Inche s because8 1 ~u power w as able to be tes ted fo r th e se m otions . A dd itiona lly, fo r th a t sam e rea son , th e ga it\ ) U ( ; J i J 7 ~ i j . / co uld n ot be a sse sse d,w d))/I~ Knees :

,/ / T h e knee s w ere non-tende r and th e tem pera ture w as no t e leva ted on pa lpa tion. T he re we re nosca rs o r le s ions no ted . T here w as no pitting edem a a t th e pa te lla and bo th knee s loo kedsym m etric , T he bulge and ba lloon tes t w ere nega tive . T he range o f m otio n on th e knees co uldno t be assessed because th e pa tient re fused th ese tes t on account o f be ing tired , T hus th eanterio r/po ste rio r d ra wer tes t, va lgus s tress te st, va rus stress te st, la ch m ann te st, M cM urraytes t co uld no t be pe rfo rm ed ,

A nkle and Fee t:T he ach ille s tendon and m eta ta rsopa langea l jo ints w ere no t pa lpa ted because th e pa tientre fused exam ina tion o f th e fee t and ankle because he s ta ted th a t h e w as tired and d id no t wantto be exam ined . T h us th e range ~fmo .tio n fo r th e Ieet cou .I d no t g e ~ v ah .~ ,te d . _ /. ..L!{tJ}((lJj{L 4.tctt!~l


9/19

Thomas Chol @ 00238569 W ritten Case Study 7/5/11

T he plantar, achilles, and patellar reflex w ere all2 t. B rudzlnsk l's and K ernlg 's sign w ere bothnegative. L ight touch sensation w as Intact In all derm atom es In the both low er lim bs. extinctiondid not occur w hen testing light touch on both sides of the low er lim bs sim ultaneously. T hep atie nt w as a ble to lo caliz e e ach to uch o ve r a ll lo we r 1 1m bd erm ato me s. V ib ra tio n s en sa tio nw as intact b ila tera lly In the fingers and toes. P roprioception at the feet w as also tested andfo un d to b e In ta ct. F le xio n, e xte ns io n, abducuon, and adduction of the hip w ere 4/ 5 In p owerfor both the right and left. P ow er for flexion and extension of the leg along w ith plantarflex ionand dorsiflexion w ere not evaluated since the patient refused these tests saying he w as tiredand did not w ant to continue w ith the exam ination.

C erebellar FunctionT he R om berg test could not be perform ed because the patient was u na ble s ta nd w ith ou tassistance. Because he could not stand, gait w as not assessed. H e w as able to perform rapidsupination/pronation of the hands and dld not have m uch difficu lty m oving his finger from hisnose to an outstretched finger held In front of h im repeatedly.

S k in a nd n ails :T he sk In w as ptnk isk , not dry bu t not diaphoretic , warm , and not too rough but not sm ooth. The sk inturgor w as slightly reduced. There w as an area of hyperplgm entatlon on the left forearm but no l e s ions ,bruises, or scaling. T he nails w ere not brittle and not clubbed. T here w ere no splinter hemorrhages /'present, T he re Is a no n-te nd er sta ge IV d ecu bitu s p re ssu re ulcer on the-left buttock that m easures 0.8

" _ . ... .~ 0 .4 e m a nd 1 cm in d ep th. T he re iS lH :i"(jd or,d raitla ge ;-o r e xu date . T he s urro un din g a re a I s scarred~~ () and th e w ound edges are intact,'T unnefl~g of 2.2 em Is present at the 1:00 posItion. T he orlglnal wound . .. ..~~ measurements at dlagnosls were -r .e co td ed to b e 4. 7 cm x 1. 1 em with a depth of 4 em . T he re w as n ote dJ, to be pain rated at a 6 /10, ..


10/19

Thomas Chol @00238569 Writte n Cas e S t ud y 7/5/11

MR I o f P elv is (ta ke n 6/3/11 fo r o st eomye lit is fo llow- up ):S erosang ulous scant exud ate w ith irregu lar u lcer m argins repo rted. M oderate right hip m etallic artifactconsistent w ith prosthesis seen alon g posterior right Ileum an d a sm all region o f m in im al subcortical T1hypointe nsity and T 2 hyper in tensity w ithout significant IV contrast enhancem ent. A m uch sm aller lessT2 hyperintense area and w ithout significant contrast enhancem ent w hen com pared to F eb. 2011 MR.M ed ial right supe rficia l bu tt subcutaneous fat has a som ew ha t fla t T 1 h vp olntense an d T 2 hyperinte nsearea seen w ith m inim al 17 m m diam eter rim -enhan cing a rea and overlyin g su perficial sk in deficit. T hearea just medial and superior to this is also sm aller than before. No new soft tissue or boneyabnorm ality is noted. D egenerative m arrow type changes elsew here along pelvis w ith m oderate lumbarspondylosis seen. C hronic pelvic m uscle atrophy and fatty Infiltration again noted greater on right vs.left.PAl lAT Chest X -Ray ( ta k en 2/19/11):N o acute abnorm alities. Left P ice line present w ith tip probably in left brachiocephalfc vein. N orm alheart slze, ~ A i . C \ ~u ~ ~ ,V1V'" \ i'\-\ \ 0 . ' ~ IFurther treatm ent revolves~d re!:!}!?.!!;Igthe.rI_s1~tors for an er pressure ulcer since this Is histhird pressure ulcer. The pdt~ ~~riilOn ~uW 'lje closely monitored to ensure that there is no/ I . / { / { ; L . / ! ./


11/19

Thoma s Cho i @00238569 Writte n Cas e S tu dy 7/5/11

To address" t ~aln cause of the problem , the Im mobility, the patient should be encouraged tocontlnue.e,!W slcal therapy. A ccording to the nursing staff, the patient should be able to w alk w ith som erehabilitation since he was able to before he was admitted to the nursing hom e after a bad fall twoyears ago. S ince then he's been reluctant to go into rehabilitation therapy and consequently sufferedsom e disuse atrophy as seen In the MRI. He should be able to regain the ability to walk and cut downthe amount of tim e h e m u st spend in bed w hich w ill greatly reduce the lik elihood of anotherpressureulcer. In any case, the patient's progress should continue to be m onitored and h(h6U id be ~C h, _dul~d,_,for another check up in a couple w eek s. J / y / c X J / I ) _ _ _ 1 1 / 1 ) '?)

. _ . ~ _ . b /~J/j~!lil)P /W " - " : : ' - ' - - - " _ . "" _ / , - -f '. Anem ia: /T he values from the C BC Indicate that the patient has a mac rocvt lc anem ia. H e also has som e p ositivesym ptom s Inclu ding occasio nal fatigue an d shortness of breath although only on exertio n. F urtherInvestiga tion Is w arran ted. P ossib le differentials In clude B 12 d eficiency, pernicious anem ia, or a resultof his chronic C OPD . M easurem ent of the patients B12 and Intrinsic factor levels along w ith thepresence or absence of hypersegm ented neutrophlls w ill help rule out the ffrst tw o possibilities. Thepatient's CBC with dlff. should be observed to see if the anemia worsens and m ore sym ptoms arise.I f H !~ -) \'-f \ , Y A p " , o , [ ( 1 h Z !.~~-?..l~NI / ul. J.0 I- t ~ v rl , ! I i " "f t~))Depression: /'

x,> T he pa tie nt has been d iagnosed w ith d epression since 3/4/11. Currently the patient stili feels som esY l.np t~ ~s su ch as fatfgue, loss of Interest, and feeling he lplessness bu t states the m ed ications are

d ){J )e lJ id fl'p g th e s itu atio n. S in ce h e Is hopeful about the m edication, the lexapro should be continued. Heshould be m onitored for thIs s itu atio n In c as e hi s depress lon gets w orse or any severe side effects lik ese izure or unu su al w eak ness occ~ ~. A dditionally, the patien t could b e e nrolled In behavioral therapyconcerning selt-valldatlon a nd p ro blem s olv in g to t rea t h is fee li ng o f.he lp le ssness .

) e -? ' l ~ )Compen sa te d CHF (dia gn os ed 10/19/10): )/) . 1 - ; / ) ) 1 / 1 V 1{~.:> ; - - O a l (/J/I;Lp{./ / r ! if Z JThe patient has no pitting edem a, no worsening of hi/shortness of breath, weight gain, or chest pain tosuggest that the C HF Is decom pensated so the current m edications of furosem ide, aspirin, and -7s piro no la cto ne s ho uld b e c on tIn ue d. P ota ss ium ci should continue to be used to counteract the ./,---/ . -_._. - '"h yp ok alemia s id e e ffe ct o f th e fu ro semid e. T he p atie nt's p ota ss ium le ve ls s ho uld b cc lb se IY )l].d nito re dI -


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. (Ii) /Written Case Study . t J ) J)I


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Thoma s Cho l @00238S69 Writte n Cas e S t ud y 7 / 5 / 1 1

he enjoys w atching television w hich is not a very active pastim e. H e should be encouraged to exerciseor find a physical activity that he can enjoy that m ak es him m ore active and burn m ore calories. HisIntak e charts shou ld be check ed to see If he Is eating exce ssively. A ddItio nally T SH and fre e T 3/T 4Ievelscould be checked to rule out hypothyroidism , However that does seem unlik ely since he has no othersymptoms such as cold Intolerance or enlarged thyroid. /. ' t.

I~O.l ~ / J , J ~9 ) { ilf


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Thoma s Cho i @00238569 Writte n Cas e S t ud y 7/5/11

Discussion

T he pa tient, M r, M .H ., p resen te d w ith a n alrea dy e stablishe d dia gn osis of S tag e IV de cub ituspressure ulcer In the right buttock . U nder this classification the ulceration at onset involved the fu llthick ness of the sk in w ith extensive dam age Including tissue necrosis or dam age to m uscle, bone, orsu ppo rting stru ctu res (H o & B ogle, 2008). This does not apply to our patient currently because he hasundergone around 10 week s of treatm ent to progress to the point w here the w ound m easures 0.8 em x0.4 cm with a 1 em depth from an Initial measurement of 4,7 em x 1,1 em with a depth of 4 em. Therewas Initially pain reported w ith an Intensity of 6/10 but now currently no pain,

T hese trnd ln gs are consistent w ith the u sual p resen tation of a stag e IV press ure ulce r. F irst off,the patient fits the usual dem ographics of the m edical condition. It Is reported that 70% o f t he sepatients are over the age of 65 and also 8.5 to 22% of patients are nursing hom e residents (~esteln & _Javaheri, 2008). The location of the ulcer Involves the sacral region w hich Is the m ost common locationfor these ulcers. The pain felt by the patient is a typical part of the presentation but it is not usuallyfrom the ulcer itself but instead from an infection and the body's response to it. M .H. also hadoste om yelitis w hich a ccou nted for th e p ain .

T he actual u lceration Is a result of Ischem ic dam age. A rteries over bony prom inences such asthe sacrum are susceptib le to com pression from pressure betw een the bone and the environm ent. F orexam ple. a patient laying supine in a hospital has pressures of 100-150 mmH g on the sacrum (S Iebers,2007). S ince It only tak es a pressure of 6070 mmHg for 1 or 2 hours before m uscle fibers start todegenerate, th is Is m ore than enough pressure for the developm ent of an ulcer, The halted flow ofblood stops the supply of oxygen to the tissues. T his leads to the Ischem ia and subsequent necrosis ofc ells r es ult in g in th e u lc er ati on .

A num ber of risk factors increase the chance of developing a pressure ulcer. T hese include_J chro nic w edk al co ndition s su ch a s he art fa ilu re, k idn ey failure , a nd chro nic obstruc tive pu lm on ary.< disease (~ In heart failure, cardiac output is lowered which Impairs blood circulation. In

k idney failure the Im paired filtration allow s for the build-up of dangerous toxins in the body w hich canleave tissues m ore prone to dam age in general. In C OPD there is less perfusion w hich m ak es sk in m orevulnerable to ischem ic dam age. The patlent was positive for a ll the listed conditions and so w as at ahigher risk for the disease. D espite these factors though, probably the m ost slgnlflcant risk factor andthe m ost lik ely cause of the ulcer for the patient is his im mobility caused by his inability to stand form ore th an 1.5 m inutes due to disuse atrophy. For this reason the patient spends all of his tim e In eitherthe supine position on a bed or sitting In a chair w ith very little change In body position.

H is lim ited m obility, cha lrfast activity, occa sion al m oisture an d th e po te ntia l p roblem for frictionand shear am ount to a score of 16 indicative of a low but significant risk on the Braden scale which Is am easure of the risk of developing th is condition. in a test involving 233 lo ng term care resid en ts, thepredictive valid ity of the test w as hIgh. It had a sensitivity of 74.1% and a specificity of 75,4% w hen thecutoff point for at risk patients w as set at 17 (de S ouza, S antos, Irl, & Sadasue 0 rj 2010). A number of


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Thoma s Cho i @00238569 Writte n Cas e S t ud y 7 / 5 / 1 1

the suggested preventative m easures com e from avoiding the categories used to rate risk on this scalesu ch as a vo iding frictio n an d shee r, u sing special b edding, reposition ing immobile patients every 2h ou rs, a nd main ta in in g a n utritio us d ie t(S ie be rs, 2007).

Treatm ent Involves debridem ent of the w ound, as needed, cleaning of the w ound Initially andw ith each dressing change w ith norm al saline, preventing infection, diagnosis and treatm ent of aninfection if one occurs, and dressing the ulcer to k eep the ulcer bed m oist and the surrounding area dry(Ho & Bogle, 2008). T he patient w as tre ated w ith these sam e p rlnclples. T he a ntib iotic calcium alginatesilver dressing w as use to both prevent infection and m aintain conditions conducive to heal ing w ithperiodic cleansing using norm al saline. A w ound vacuum w as suggested for the patient so that thenegative pressure w ould also help prom ote w ound healing along w ith the dressing by creating anenvironment that promotes cell m igration and proliferation. A newer therapy was tested on a group ofthree spinal cord injury p atie nts w ith chronic stage IV pressure ulcers w hich show ed that u sing platelet-rlch plasm a therapy causes the susta ined release of large quantities o f autologo us grow th factors,cvtoklnes, and other m ediators found In the plasm a and m ay stim ulate w ound healing, resulting toreduced ulcer area and volum e versus standard th erapy (S en, E rick sen, Rels, Dros te , Bhulyan, & Gater,2011).

A s m entione d earlier, th e diagn osis w as alread y establishe d In th is patient so differen tia ls w er~n ot necessary. H ow ever, the y w ould have been < !!terlal ulcers, ve~ us u lcers, or .n el.lropathtc ulcers ( H _ Q . J . . -& Bogie, 2008). In both arterial ulcers as well as with neuropathic ulcers there would have been a ~punched out appearance to the lesion which does not fit the description of this ulcer at the onset. r?l ~Add itio na lly, w ith n eu ro pa th ic u lc ers , the patient was not a diabetic and also he did not have any : :: tM ~problem s w ith sensation over the sacral region from the physical exarnlnatlon w hich also helps to rule..N , ~this differential out. Venous ulcers are commonly found below the knee and usually in people w ith a ~history of blood clots either the superficial or deep veins of the leg w hich m ak e this differential lesslikely.


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T ho m as C ho i @ 00238569 W ritte n C a se S tu dy 7/5/11

Works Cited

Bluestein, D ., & Ja va he rl, A . (2 00 8). P re ss ure U lce rs : P re ve ntio n, E va lu atio n, a nd M a na ge m en t. AmericanF am U y P h ys ic ia n , 1 1 86 -1 1 94.d e S ou za , D ., S a nto s, V., I ri , H . , & S ad as ue O gurl, M . (2010). P re dictiv e v alid ity o f th e B ra de n Sca le fo rP re ss ure U lce r R is k i n e ld erl y re sid en ts o f lo ng -te rm ca re fa cil itie s. Ger lot r Nurs , 95-104.Ho , C . H., & B og ie , K . (2 00 8). C h ap te r 1 40 : P re ss ure U lce rs . In W . R . F ro nte ra , J. K.Sl iver , & T . D . R i zz o J r.,Essentials of P hys ica l M ed ic in e a nd R eh ab ilita tion , 2n d ed . ( pp . 8 13 -8 21 ). P h il ad e lp hI a: S au nd e rs .S e l l, S ., E r ick sen , J., Re is , T . , D r o st e, l" Bh ul ya n, M ., & Gate r, D . (2011). A case repo rt on th e use o fsus ta ined re lease pla te le t-rich plasm a fo r th e trea tm ent o f ch ro nic pressure ulcers . J Sp in a l Cord M ed ,122-127.S ie be rs , M . J, (2007). C ha pte r 20: P re ssure U lce rs . In E . H . D u th ie , & P . R . K atz, P ra ctic e o j G erk nr lc s, 4 thed . (pp. 245-254). P h il a de lp h ia : S a un d er s.


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R o ss U niv ers ity A 1CM Writte n C a se Study Eva lua tion Form ,-)

T he A IC M W rit 'e . C ase Study will b e g ... de d a cc ord in g to th e s pe cific c rite ria p ro vid ed in a n e ffo rt ' 0~tubjectiv ity o f the g rad e . ,S tud ent N am e: ~\'Vl.M C f \ . 0 1 . ,Evalua tor : iC = . g . k A . O .1. Chi e f Complaint (2 .5 p t)Excel lent (2.5p): R e as on fo r e va lu atio n, in p atie nt w o rd s If'posslbleGood (1 .5 ~2 p): R e as on fo r e va lu atio n is n eb ulo usPoo r (Il-Ip): Reason f or e v al ua tio n d o e s n o t ma t ch HPI2. History' o f Present I l lness with Source of in fo rmat ion and s ta tement of r el ia bil lty ( 25 p ts )Excel lent (25p): So ur ce o f in fo rma t io n and s ta teme n t o f r el ia bil ity w e re in cl ud e d, a cc ord in g to g uid eline s. H isto ry o fPresent I l lness provided an o p en in g s ta teme n t in cl ud in g ago , ra ce , g en d er , pertinent PMH a nd so cia l h is to ry. T he HPIincluded a th oro ugh d es criptio n o f th e c hie f c om p la int, w as ch ro no lo gic al w ith g oo d flo w a nd a c omp le te l is t o f pertinentp o sitiv e a nd n eg ativ e h is to ric al fa cts fROS . C o r re ct m e d ic al te rm i no l og y.G o od (l 6.2 4.5 p): R e as on ab ly g oo d b ut in comp le te d es crip tio n of'the c hie f c omp la in t a nd /o r l ist o f p ertin en t p os itiv e a ndn eg ativ e h is to ric al fa cts . R e as on ab ly g oo d fl ow and med ica l terminology,S atis fa cto ry (8 -1 S,5 p): In comp le te d es crip tio n o f th e c hie f c omp la in t a nd l is t o f p ertin en t p os itiv e a nd n eg ativ e h is to ric alfa cts ; m e d ic al te rm i no lo gy ! fl ow in ad eq ua te a nd n ot c hro no lo gic al in n atu reP o ol'(1 -7 .S p): C o nte nt a nd te rm i no lo gy a re in ad eq ua te

3. Pas t Me dica l, S urg ic al H is to ry , A lle rg ie s, M e ds , S ocia l and Fa m ily H is to ry (10 pts) C o l 5'E xce lle nt (lO pts ): T h e P / J r u a nd P $U ;;e co m ple te a nd p ro vid e d ate s o f d ia gn os is a nd th e d ia gn os in g p ro vid er, if 0a va il ab le . C h il dh o od ill ne ss a re in clu de d ifp ertin en t. R e la tiv e A d ul t Ill ne ss es a re in cl ud ed a cc ord in g to th e g uid el in es inBa te s. T h e s o cia Lbis t6 ry in cl ud e s a ll a sp ec ts o f th e patient's s o cia l s ta tu s. T I le Fami lyHx . i nc l ud e s p e rt in e nt in fo rma ti on ,e s pe c ia l ly r eg a rd i ng cond it io n s with a g en etic c omp o ne nt. A l le rg ie s (to m e d ic atio ns a nd e nv iro nm e n t) w e re lis te d withty pe o f re ac tio n, w h en in fo rm a tio n a va il ab le . M e dic atio ns w e re l is te d c orre ctl y, w ith a cc ura te d o se s a nd fre qu en cy .P re ve nta tiv e m e d ic in e a nd immu n iz atio ns w e re d o ne a cc ord in g to g uid el in es , in cl ud in g d ate s o f v ac cin atio ns andscre ening te sts . .G o od (6 -9 .5 pts ): In comp le te o r in co rre ct in fo rm a tio n inone o r tw o o f th e a bo v e l is te d a re a s.Satisfactory (3 ~ 5.5 pts ): In comp le te o r in co rr ec t in fo rma t io n in two or 3 ofthe above listed areas .P o ol '(1 -2 ,5 ): In comp le te a nd lo r i nco r rec t i n fo rma t ion in 4 o r m ore area s ;

4 . R ev iew o f System s (10 pts) toE xc elle nt (lO p): Info rm a tio n is b ul1 ete d a cc ord in g to s ys te m a nd in a h ea d to to e fa sh io n. C o rre ct m e dic al te rm in olo gyus ed ; s ys te m s a re re vie we d c om p re he nsive ly, a cc ord in g to gu id elin es in B ate s. T h e re vie w is ta ilo re d to th e p atie nt'sunique s ta tus based o n P lvffi, age and gend er. A U po sitives a re e xplo red . A ll 15 s ys tem s a re r ev iew ed .Good (6w9.5p): A dequa te list o f syste m s a nd sym pto m s pe r sys tem with a fe w m i ss in g! in co rre ct e le m e nts .S atis fa cto ry (3 -S .5 p): M o re th an o ne s ys te m m is sing a nd inc om p le te ! inc orre ct re po rting o f s ym p to m s.P oo r (lM2.5p ): In co m ple te / inc orre ct info rm a tio n in m u ltiple a re as o f th e R O S . V, o~\ 0 0 , 1 , " 0

612011 0


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R o ss U niv ers ity A ICM Writte n C a se S tu dy E va lu atio n F orm

5. P hysica l E xam ina tio n w ith Lab and D iagno s tics (2 5 p ts )E xc el le nt (2 5p ): Co rre ct m e d ic al t erm i no lo g y u se d ; o b je ctiv e findings o f th e e x am i na tio n o f e ach s ys tem a re re po rte d ina h e ad -to -to e fa sh io n, in a comprehensive ye t c on ci se m anne r (in cl ud in g p ert in en t n e ga tiv e findings). Ifavailable-anda pp ro pria te , C BC a nd BMP (e le ctro ly te s, B UN , C re atinin e), a ls o G FR a nd ca lcu la te d cre atin ine cle ara nce (C o ck cro ft- __ _._Gau lt equa ti on ) a re included in th e la b section. Ifa ll a re n orm a l, th en o th er p ertin en t l ab s ( TSH , lip id s e tc) o r te stre su lts /(E ch o ca rd io gram , ERG CXR 'e tc ) a re a ls o in clu de d (b es id es eBC a nd BMP). T he a bn orm a l la b find ing s! te st re sults w ereincluded in th e A & P sect ion .Good (16- 24 .5p ): A de qua te re po rtin g o f th e e xa m ; s ys te m s lis te d in a h ea d-to -to e fa sh io n w ith s om e m is sin g! in co rre ctin fo rm a tio n o r l ac k o f c on cis io n,Satisfactory ( 8- 1 5 .5 p ): O ne o r m ore syste m m issing a nd I nc omp l et e/ i nc o rr e ct r epo rt ing o f exam inat ion .POOl' V-7.5p): I ncomp le te ! i nc o rr ec t i nf orma ti on inmult ip le a re as o f th e PE6. Assessment and Management P lan (25 pts )Excellent (25 p ): Stud en t re po rts a co m ple te lis t o f d ia gno se s: ne w (a cute ) a nd o ngo ing (ch ro nic) co nd itio ns . F or e achm e dica l p ro blem , th e s tu de nt id en tifie s th e m o st lik ely d ia gn os is w ith a b rie f d iffe re ntia l o f o th er d ia gn os tic p os sib il itie s.T he e tio lo gy o r ca us ative fa cto r fo r th e pro ble m (s ) a nd th e s ta tu s o f th e pro ble m (s ): a cute ! chronic/ re s ol ve d a re c orre ctl yid entifie d a ls o a nd a pla n fo r p ro ving d ia gno sis (a ppro pria te inv es tig atio ns ) is p ro vid ed , T he s tu de nt a lso p ro vid es a pla nfo r p ha rm a co lo gic al m a na gem en t in cl ud in g s id e e ffe cts and co m plica tio ns o f th era py a nd p la ns fo r d ie ta ry, s ocia l o r o th era spe cts o f m a na ge m ent. C o rre ct m e dica l te rm in olo gy is u se d a nd th e A& P is concise. .Go o d ( 16 -2 4.5 ): A cc ep ta ble b ut in com ple te lis t o f d ia gn os es o r in com ple te / p artia lly in co rre ct investigations/ t r eatmentr e commenda t i o n s / i nt er pr et at ion o f e ti o logy,Satisfactory (8M15.Sp): A s ig nifica nt n um b er o f d ia gn os es a re m is sin g a nd a s ig nifica nt n um b er o f in ve stig atio ns !tre atm e nt re comm e nd atio ns a re in com ple te o r in co rre ct,POOl' ( lM7 .5 ): Mo st o f th e d ia gn os es a nd re comm e nd atio ns are miss ing! incor rec t.7 . Fo rm at (2 .5 pts )Excellent (2.5 p): Stu de nt fo llo we d th e co nve ntio na l h is to ry a nd ph ys ica l fo rm a t, inclu din g co rre ct s pe llin g a nd pa pe r iswritten inM A format .Satisfactory (1-2p): O ne o r m o re co m po ne nts m is sing! in fo rm a tio n inclu de d in a d iffe re nt co m po ne nt o f th e ~ ite "upth an th e o ne s pe cifle ~ in g uid e~ in ~s {~ in or s pe ll in g e ~o rs /e rro rs inAP A f~ rm at.. / ( 1 7 0 \ . : 1* Th e p ap er ~ ay re qu ire re m ed ia tio n If there IS a c on sis te nt p atte rn o f s pe llin g e rro rs , < 3 S ~ . . , < ; . ~T o ta l S co re >" ---]toO

If failure, remedlatlon due date: _Da te d is cu ss ed with student: - - - - - - - - - - - - - - _ - - - - -Signature of Student: _ Signature of'Preceptor: _

6/2011


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Ross Unive r si ty A f C M Writte n C a se S tu dy E va lu atio n F orm

Discussion Content and Grading1. G eneric path oph ysio lo gy discussio n (20 pt): I S '

l i st s character is t ics of th e p rin cip le d ia gn os is w ith d is cu ss io n o f d is ea se In detaillncludlng d ia gn os tic c rite ria a nd s pe cif ic fin dIn gs th a t th e pa tie nt pre se nte d w ith(HP I, PMH, R OS, FH , PE , L abs) w ith co m pa riso n to ty pic al d is ea se presentation,as per medlcal llterature.

Good: lists so m e o f th e ch ara cte ristics o f d ise ase pro ce ssPoor: D oes no t list characterIstics o f the d isease process; does no t com pare to typica l

d ise ase o r re la te to th eir pa rticula r pa tIe nt

Excellent:

2. Correct d ia gn os is a nd d ls cu ss lo n o f th e d iffe re ntia l d ia gn os es (1 0p t)Excellent:Goo d :Poo r :

D ia gn os is is c orre ct w ith g oo d d ls cu ss lo n o f d iffe re ntia lsD i agno s is I s co rr ec t bu t d is cu ss io n o f d if fe re n ti al Is no t comp re h ens iv eD ia gno sis Is In co rre ct o r d lffe re ntla ls n ot lis te d

3 . Rationale fo r tre atm e nt pla n wIth co mpariso n to th e m ed ica l litera ture (10pt) qExcellent:

Good:Poor:

Ra t iona le appropr ia te , comprehensIve w ith e xce lle nt co m pa riso n to cite dliterature

Rationale Is a ppro pria te , no t a s co m pre he nsive w ith go od co m pariso n toCi ted l it er a tu reR a tio na le Is m I ss In g o r POO fl no t co mprehensive: no co mparison to d ted

Literature54. C crre ct fo rm a t/ le ngth (5pt)

Poor (2.5 p): less than one and grea ter than 4 pages In length5. References (5pt):

Excellent:Poor :

7-11

5~ to ta l (2 w id ely accepted textbo oks and 3 review articles fro m peer rev iewedJo urna ls less th an 5 years o ld )less than the above num ber o f resources o r o ld er than 5 years

Total: ! 1 b /50

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