Running head: PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 1
Primary Care of Adults across the Lifespan
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PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 2
NURS 6531 WK 6
Practicum Experience Journal
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Preceptor’s Name:
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Subjective
CC: Abdominal pain, bloating, nausea, difficulty swallowing, hoarsens, and a tight, swollen
stomach. The patient also reports to a weight loss of17.2 Ibs over the past three months.
L = stomach
O= stomach discomfort over the last three months
C= tight swollen stomach.
A= Abdominal pain bloating, nausea, difficulty swallowing, 17.2Ibs weight loss.
T= discomfort present all the time
E= Nothing relieves the pain
S= Mild pain ranging 6/10
HPI: A 46-year-old African -American female presents to the clinic with abdominal pain,
bloating, nausea, difficulty swallowing, hoarsens, and weight loss over the past three months.
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 3
The patient has a history of GERD that has been well controlled with Omperazole and
Ranitidine. She denies any diarrhea, vomiting blood, or bloody stools.
PPMH: Has a history of GERD. No previous hospitalizations.
PSH: No past medical surgeries.
Family Med Hx: Both parents are deceased. Father had a history of hypertension. Mother had a
history of diabetes and hypertension.
Social Hx: Single mother of five children. Smokes a packet a day, non-drinker and has used
marijuana in the past. She performs physical exercise but not regularly. She is a member of the
Baptist faith. Reproductive/Sexual: Denies sexual activity in the past two years.
Allergies: Has a penicillin allergy
Immunizations: Current on all immunizations but has not yet received an influenza vaccine.
Medications: Omperazole 20MG 1 tab in AM, Ranitidine 150MG BID
SUBJECTIVE
ROS:
General: No reported fever or rashes. Has lost 17.2 Ibs over the past three months.
Neuro: generalized weakness. Reports no head ache, dizziness, and confusion or memory
problems.
HEENT: Reports hoarseness. Denies visual changes, headache, sinus pressure, ear pain, throat
pain. Respiratory: Denies any respiratory complications.
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 4
Cardiovascular/Peripheral Vascular: Denies any chest pain, palpitations or edema.
Gastrointestinal: Abdominal pain, bloating, nausea.
Genitourinary: Does not report any changes in the urinary pattern. No rashes or complications in
the genital areas.
Musculoskeletal: Does not report any joint pains, difficulty in coordination, or mobility
problems.
Skin: Denies the presence of rashes or lesions.
OBJECTIVE
Vital signs: Temp 98.6, HR 90 BPM, BP 103/67 mm HG, O2 100% RA, Weight, 48.63 Kg BMI
18.99 Index
General: Well developed, pleasant, and cooperative.
Neurologic: Non-focal.
Psychiatric: Alert, oriented, cooperative with the exam. Appropriate mood, and affect. Can
answer most questions and have no memory problems.
Skin: No suspicious lesions or rashes.
Hair: Normal texture, thinning, and distribution.
Nails: Brittle nail with a whitish color.
HEENT: Head: No headache, no masses. Eyes: No tearing, clear conjunctiva, normal eye color.
Ears: No observable lesions or rashes, no abnormal discharge. Nose: No observable lesions or
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 5
abnormal mucus production. Mouth: Mucosa is moist with no mucosal lesions. Teeth/Gums:
Missing several molars. Hoarsens in the patient’s voice.
Neck: Supple, full range of motion, no cervical lymphadenopathy.
Chest: Chest symmetrical, symmetrical expansion. No nipple deformity. No accessory muscle
use. No masses or tenderness to palpation.
Lungs: Clear A/P bilaterally on auscultation.
Abdomen/GI. Distended, hyper bowel sounds with a lot on gurgling, non-tender on palpation,
unable to palpate liver margin.
Musculoskeletal: Normal.
Hematologic: Absence of edema or bleeding complications.
Endocrine: weight loss of 17.2 Ibs for the past three months. No noticed fever, chills, or
excessive sweating.
Diagnostics:
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 6
To determine the diagnosis for the patient, in this case, we performed a blood cell count
on a sample of blood collected from the patient. The results indicated neutropenia, moderate
anemia. We also performed a urine test which indicated hypokalemia.
For further diagnosis, the patient will undergo an esophagogastroduodenoscopy (EGD).
The procedure involves using a thin, flexible tube inserted through the mouth and pushed
through the pharynx, esophagus, stomach, and duodenum (Buie, Campbell, Fuchs, Furuta, Levy,
VandeWater, & Carr, 2014). The endoscope uses a charged video chip for better imaging inside
the gastrointestinal system (Buie et al., 2014). It is used while the patient is conscious or under
moderate sedation (Buie et al., 2014). An EGD is used to diagnose upper gastrointestinal
diseases, surveillance of upper gastrointestinal cancer, or for therapeutic purposes (Buie et al.,
2014).
We will also send the patient for a colonoscopy. A colonoscopy is a medical procedure
that investigates the inside of the large intestines (Buie et al., 2014). It is used to check for
symptoms of intestinal bleeding and abdominal pain discomfort (Buie et al., 2014). A
colonoscopy can also be used to check for cancer (Buie et al., 2014). The procedure is performed
using a long flexible tube that provides an image of the walls of the colon (Buie et al., 2014). The
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 7
tube is inserted through the rectum and pushed to the other parts of the large intestine (Buie et
al., 2014). A colonoscopy takes place under general anesthesia or when the patient is still
conscious (Buie, et al., 2014).
Other diagnostic procedures that can be performed for the patient, in this case, include
computerized tomography (CT) scan. This is a combination of x –rays and computer technology
performed to provide an image for the inside of the esophagus and stomach (Buie et al., 2014).
The procedure allows the doctor to visualize any abnormalities. An esophageal manometry test
can also be used to measure the strength and coordination of the esophageal muscles (Buie et al.,
2014).
Further lab tests may also include a urea breathe test. The procedure involves giving a
liquid that contains urea to the patient (Buie et al., 2014). The patient takes the liquid, and if she
has H.pylori bacteria, the bacteria will break down the urea in carbon dioxide (Buie et al., 2014).
The carbon dioxide appears in the patient’s breath when she exhales (Buie et al., 2014). The
physician takes a sample of the breath and sends it to the lab for sampling (Buie et al., 2014).
High levels of carbon dioxide indicate H.plori bacteria (Buie et al., 2014). A stool test may also
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 8
be used to check for the presence of H.Pylori bacteria (Buie et al., 2014). The doctor collects a
sample of the patient’s stool and sends it to the lab for analysis (Buie et al., 2014).
Assessment:
Primary Diagnosis:
Gastric cancer. Gastric cancer is a condition in which cancer cells form in the stomach
lining (Correa, Haenszel, Cuello, Tannenbaum, & Archer, 2015). The stomach contains walls
that are made up of five layers: the mucosa, sub mucosa, connective tissues, and serosa (Correa
et al., 2015). When an individual acquires gastric cancer, it starts from the mucosa and spread to
the outer layers (Correa et al., 2015). The risk factors for gastric cancer include having a
gastrointestinal condition, eating highly salted or smoked foods, and smoking (Correa et al.,
2015). Being older and having a family history of stomach cancer may also increase the risk of
gastric cancer (Correa et al., 2015). The symptoms of gastric cancer manifest depending on the
stage of the disease (Correa et al., 2015). Early symptoms include stomach discomfort, bloating,
nausea, loss of appetite, hoarseness, and heartburn (Alberts, Cervantes, & Van de Velde, 2015).
Later stages symptoms include stomach pain, trouble swallowing, abnormal weight loss,
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 9
vomiting, blood in the stool, and a buildup of fluid in the stomach (Alberts et al., 2015). I
selected gastric cancer as the primary diagnosis because the patient, in this case, showed most
symptoms discussed above. The symptoms were difficulty swallowing, stomach pain, bloating,
nausea, abnormal weight loss, hoarseness, and a tight, swollen stomach. Though the patient did
not show some of the symptoms such as bloody stools and vomiting, she is most likely suffering
from gastric cancer. Another reason why I selected gastric cancer was that the patient has a
history of gastroesophageal reflux disease (GERD), which increases the chances of acquiring
gastric cancer. The lab results also indicated anemia and neutropenia, which are also signs of the
presence of cancer. However, the diagnosis might not be accurate, and further lab tests are
needed to determine the exact diagnosis.
Differential Diagnosis:
Barrett’s Esophagus. This is a gastrointestinal condition that replaces the tissues in the
esophagus with tissues similar to the intestinal lining (Spechler & Goyal, 2016). Symptoms
include difficulty swallowing, stomach discomfort, nausea, heart burn, vomiting, and less
commonly, chest pain (Spechler & Goyal, 2016). There is no known exact cause of Barrett’s
esophagus, but having a history of gastroesophageal reflux disease (GERD) may increase the
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 10
chances of acquiring the disease(Spechler & Goyal, 2016). In GERD, stomach contents go back
to the esophagus damaging the esophagus tissue (Spechler & Goyal, 2016). Other risk factors of
Barrett’s esophagus are being old, smoking, excessive weight, being white, and having chronic
heartburn or acid reflux (Spechler & Goyal, 2016). Barrett’s’ esophagus may increase the risk of
esophageal cancer if it is not treated (Spechler & Goyal, 2016). The patient, in this case, might
be having Barrett's esophagus because she has a history of GERD. The patient also showed some
symptoms of the disease, such as difficulty swallowing, nausea, and stomach discomfort. Further
laboratory tests are needed to determine the diagnosis.
Peptic ulcers. These are sores that occur in the inside lining of the upper portion of the
small intestine and the stomach (Ramakrishnan & Salinas, 2017). They are commonly caused by
H.pylori bacteria or the long-term use of non-steroidal anti-inflammatory drugs (Ramakrishnan
& Salinas, 2017). Symptoms include stomach pain, bloating, nausea, heart burn, unexplained
weight loss, changes in appetite, and vomiting (Ramakrishnan & Salinas, 2017). The patient, in
this case, could be having peptic ulcers because she showed symptoms such as nausea,
unexplained weight loss, nausea, and bloating. However, further lab tests and an investigation on
the patient's lifestyle and medical history should be done to confirm the diagnosis.
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 11
Hiatal hernia. The diaphragm has a small opening known as the hiatus through which the
esophagus passes to connect with the stomach (Ellis, Crozier, & Shea, 2016). If an individual
has hiatal hernia, the stomach bulges through the hiatus into the chest (Ellis et al., 2016). A small
bulge usually does not cause compilations, but a large one allows food and acid back to the
esophagus, which might cause complications (Ellis et al., 2016). Symptoms of hiatal hernia
include heartburn, difficulty swallowing, abdominal pain, breath shortness, vomiting, and acid
reflux (Ellis et al., 2016). Though the patient, in this case, showed a few symptoms of hiatal
hernia, the diagnosis can only be confirmed after further lab analysis.
Indigestion. Indigestion is a term used to refer to upper abdomen discomfort. Indigestion
is not a disease but a symptom in which one experiences a feeling of fullness and abdominal pain
(Puylaert, 2017). Though indigestion is common, different people experience indigestion
differently, and the symptoms may be felt occasionally (Puylaert, 2017). Indigestion can be an
indicator of another digestive disease; thus, medical intervention is necessary (Puylaert, 2017).
The symptoms of indigestion include stomach discomfort, bloating, nausea, and hear burn. Less
common symptoms include vomiting and belching (Puylaert, 2017). The patient, in this case,
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 12
may be having indigestion but may also have other stomach compilations. Further diagnostic
tests are needed to determine her diagnosis.
Plan:
Medication discontinued: N/A
Medication started: N/A
Alternative therapies: The patient, in this case, is suspected of having cancer. Before starting
treatment, we will conduct various tests to confirm the diagnosis and to determine the stage of
cancer. However, while waiting for the results, various interventions will be used to improve the
quality of life of the patient. We will work with the patient to determine the best interventions
for her symptoms. The patient is likely to experience stress when she learns about her diagnosis.
To manage stress, we will recommend meditation, music therapy, or various relaxation
techniques to reduce anxiety. Physical exercise can also be used to manage patient stress and
improve her general quality of life (Lamb, Brown, Nagpal, Vincent, Green, & Sevdalis, 2014).
Therefore, we will work with the patient to create a regular exercise plan.
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 13
Health promotion strategies: The patient and her family need to understand the importance of
adhering to treatment and attending all the doctor's appointments. We will first educate her on
the importance of strictly following all medical recommendations. We will also educate her and
her relatives on how to keep appointment reminders. The patient may also require dietary
changes; thus we will create a nutritional with for the patient to ensure she consumes a healthy
diet. Some of the priority food that will be recommended include high protein foods such as soy
foods, fish, and nuts. Carbohydrates are also important for physical activity and proper organ
function. Sources of carbohydrates include fruits, vegetables, and whole grain foods. Foods rich
in vitamins and minerals such as vegetables are also a requirement in cancer patients. The
patient will also need to take eight glasses or more of liquid each day.
Diagnostic tests ordered: The patient has been scheduled for a colonoscopy and
esophagogastroduodenoscopy (EGD) for further assessment. The results are expected in two
weeks' time. If the results confirm a cancer diagnosis, we will perform further lab procedures to
determine the stage of her cancer. Some procedures that may for cancer staging include
endoscopic ultrasound, PET scan, CAT scan, MRI, and laparoscopy (Alberts et al., 2015). The
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 14
staging procedures will be performed within the first week after the confirmation of the
diagnosis.
Disease prevention strategies: Various treatments can be used in the treatment of gastric cancer.
We will evaluate the various treatment options before selecting the most suitable for this case.
The treatment option selected will also take into consideration the facilities available in the
facility. Some procedures that we might use for treatment will include the following:
Surgery. Surgery can be used to treat gastric cancer. There are two types of surgeries. Subtotal
gastrectomy and total gastrectomy (Alberts et al., 2015). A subtotal gastrectomy involves the
removal of the part of the stomach that contains cancer and other tissues and organs near the
tumor (Alberts et al., 2015). A total gastrectomy, on the other hand, requires the removal of the
entire stomach and other tissues surrounding the tumor (Alberts et al., 2015).
Endoscopic mucosal resection. An endoscopic mucosal resection uses an endoscope to remove
precancerous growths and early stage cancer from the lining of the digestive tract (Alberts et al.,
2015). The procedure does not require surgery.
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 15
Chemotherapy. This is a form of treatment that uses drugs to stop the spread of cancer cells
(Alberts et al., 2015). Chemotherapy works by either killing the cells or stopping them from
multiplying (Alberts et al., 2015). The drugs are taken by mouth or injected into the blood stream
and can reach cancer cells found in the body (Alberts et al., 2015).
Radiation Therapy. This is a form of cancer treatment that uses radiation to kill cancer cells or to
prevent them from growing (Alberts et al., 2015). There two forms of radiation therapy; external
radiation therapy and internal radiation therapy. External therapy uses a machine outside the
body to send radiation to cancer (Alberts et al., 2015). Internal therapy uses radioactive
substances such as wires or seeds that are placed directly on cancer (Alberts et al., 2015).
Immunotherapy. A treatment that utilizes the patient's immune system to fight cancer. A
substance made in a laboratory or by the body is used to defend the body against cancer.
Targeted therapy. A form of cancer treatment that uses drugs or other substances to attack
particular cancer cells without harming normal cells (Alberts et al., 2015).
Chemo radiation. A combination of radiation and chemotherapy to kill cancer cells or prevent
their growth (Lamb et al., 2015).
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 16
Referrals: We have consulted the hematology and oncology for possible urgent care and
treatment for the patient. We will also refer the patient to a mental health practitioner to offer
psychological support to the patient. We might also refer the patient to a nutritionist who will
work with the patient to optimize the patient’s nutritional results. A support group and a spiritual
group may also be necessary to improve the patient’s quality of life.
Follow up: The patient is required to visit the clinic every week for close monitoring of her
symptoms and provide immediate interventions if needed.
Reflection:
This week's tasks allowed me to understand the implications of different gastrointestinal
symptoms. I was surprised to learn that some symptoms such as abdominal pain and bloating are
usually ignored, but they may be indicators of serious medical complications such as cancer. I
also learned that some gastrointestinal complications such as gastro esophageal reflux disease
should be treated as soon as they are detected because they can lead to serious complications. I
also learned that neutropenia and anemia are symptoms of cancer. I also understood various
diagnostic procedures such as endoscopy and a stool test that can be to assess gastrointestinal
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 17
symptoms. The experience also allowed me to acquire knowledge of different forms of cancer
treatment. I also came to understand the importance of collecting a thorough patient history
during diagnosis. In future practice, I will apply the skills obtained from this experience when
providing care to other patients.
________________________
Preceptor Signature and Date
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 18
References
Alberts, S. R., Cervantes, A., & Van de Velde, C. J. H. (2015). Gastric cancer: epidemiology,
pathology, and treatment. Annals of Oncology, 14(suppl_2), ii31-ii36.
Buie, T., Campbell, D. B., Fuchs, G. J., Furuta, G. T., Levy, J., VandeWater, J., ... & Carr, E. G.
(2014).Evaluation, diagnosis, and treatment of gastrointestinal disorders in individuals
with ASDs: a consensus report. Pediatrics, 125(Supplement 1), S1-S18.
Correa, P., Haenszel, W., Cuello, C., Tannenbaum, S., & Archer, M. (2015). A model for gastric
cancer epidemiology. The Lancet, 306(7924), 58-60.
Ellis, F. H., Crozier, R. E., & Shea, J. A. (2016). Paraesophageal hiatus hernia. Archives of
Surgery, 121(4), 416-420.
PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 19
Lamb, B. W., Brown, K. F., Nagpal, K., Vincent, C., Green, J. S., & Sevdalis, N. (2014). Quality
of care management decisions by multidisciplinary cancer teams: a systematic
review. Annals of Surgical Oncology, 18(8), 2116-2125.
Puylaert, J. B. (2017). Ultrasonography of the acute abdomen: gastrointestinal
conditions. Radiologic Clinics, 41(6), 1227-1242.
Ramakrishnan, K., & Salinas, R. C. (2017). Peptic ulcer disease. American Family
Physician, 76(7).
Spechler, S. J., & Goyal, R. K. (2016). Barrett's esophagus. New England Journal of
Medicine, 315(6), 362-371.