CONCEPT: CELLULAR REGULATION
TOPIC: Cancer – Hematology/Oncologic Emergency

Ms. Y is a 44-year-old woman diagnosed with non-Hodgkin lymphoma (NHL) 3 months ago. She finished receiving her third of six chemotherapy courses 5 days ago. Yesterday morning, she was seen at her oncologist’s office for malaise, muscle weakness, and palpitations. She had splenomegaly on examination. A computed tomography (CT) scan of the abdomen showed metastatic disease in the liver and spleen. She is admitted to the hospital with progressive weakness.
Name 3 risk factors for lymphoma.
A.
B.
C.
Chart View
Comprehensive Metabolic Panel (CMP)

Na 139 mEq/L
K 6.3 mEq/L
Cl 96 mEq/L
CO2 28 mEq/L
Glucose 101 mg/dL
Blood urea nitrogen (BUN) 59 mg/dL
Creatinine 2.5 mg/dL
Ca 6.9 mg/dL
Total protein 5.4 g/dL
Albumin 2.8 g/dL
Phosphorus 4.9 mg/dL
Uric Acid 21 mg/dL
Total bilirubin 0.8 mg/dL
Alkaline phosphatase 172 units/L
Aspartate transaminase (AST) 254 units/L
Alanine transaminase (ALT) 74 units/L
Lactate dehydrogenase (LDH) 214 IU/L

Interpret Ms. Y’s admitting comprehensive metabolic panel results.

Based on the laboratory test results, which common oncologic emergency is Ms. Y experiencing?

Describe the pathophysiology of this condition.

What assessment findings related to this diagnosis would you expect in Ms. Y?

Complete Blood Count (CBC)

White blood cells (WBCs) 1500/mm3
Neutrophils 66%
Lymphocytes 16 %
Monocytes 15%
Eosinophils 5%
Hemoglobin (Hgb) 7.9 g/dL
Hematocrit (Hct) 22.4%
Platelets 21,000/mm3

Interpret the lab values above.

Name 3 additional problems for which Ms. Y is at risk.

What are your nursing priorities right now and why?

Medication Record

IV 0.9% normal saline at 150 mL/hr
100 mEq sodium bicarbonate (NaHCO3) in the first liter of the IV fluid
rasburicase 6 mg IV now
allopurinol 500 mg twice a day orally
furosemide 40 mg IVP now then every 6 hours
sodium polystyrene sulfonate (Kayexalate) 15 g orally every 6 hours
aluminum hydroxide 2 caps orally with meals

What is the expected outcome associated with each medication Ms. Y is receiving?
normal saline
NaHCO3
rasburicase
allopurinol
furosemide
Kayexalate

What are your nursing responsibilities when administering Kayexalate?

Discuss 2 major complications that could happen if Ms. Y’s abnormal laboratory test results (CMP results) will not be resolve?
A.
B.

Name 3 signs and symptoms for each of the following problems.
A. anemia
B. neutropenia
C. thrombocytopenia

List at least 7 independent nursing interventions that you would include based on the client’s abnormal laboratory test results.
A.
B.
C.
D.
E.
F.
G.
Comprehensive Metabolic Panel (CMP) day 2

Na 136 mEq/L
K 4.7 mEq/L
Cl 104 mEq/L
CO2 26 mEq/L
Glucose 110 mg/dL
Blood urea nitrogen (BUN) 36 mg/dL
Creatinine 2.1 mg/dL
Ca 7.9 units/L
Total protein 5.4 g/dL
Albumin 2.8 g/dL
Phosphorus 4.1 mg/dL
Uric Acid 2.0 mg/dL
Total bilirubin 1.0 mg/dL
Alkaline phosphatase 94 units/L
Aspartate transaminase (AST) 46 units/L
Alanine transaminase (ALT) 44 units/L
Lactate dehydrogenase (LDH) 222 IU/L

Interpret Ms. Y’s latest lab results by comparing it with the previous laboratory test results 24 hours ago.

If you think that the client’s condition is resolving, what other interventions would you include in her plan of care?

List at least 5 other oncologic emergencies and give at least two nursing interventions for each.
A.
B.
C.
D.

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A nurse in an outpatient infusion clinic discusses with a friend the admission of a woman community leader who is receiving treatment for cancer. The nurse’s friend then talks to others, who talk to still others, until there is widespread knowledge of the patient’s cancer in the community. The woman’s daughter hears about her mother’s cancer diagnosis at school and is very upset. (3 points)
What recent act was violated in the initial conversation?
Discuss at least 2 ethical principles that are involved in this situation.
What are the ramifications for this case?
Who is at fault?
Mrs. Cole is admitted with uncontrolled diabetes mellitus. She has a saline lock in place in her left wrist area. A symptomatic drop in blood sugar to 38 requires she receive 50 ml of 50% dextrose infused at 3 mL/min via the peripheral infusion site. She responds well, but the next day needs another dose of dextrose via the same infusion site for a second drop in blood sugar. At discharge, she complains of burning and pain at the site. The nurse documents that the catheter is intact on discontinuation of the peripheral catheter, but no assessment data or subjective patient complaints are recorded. The patient is admitted three days later with purulent drainage form the left wrist infusion site, temperature of 101 degrees F, and pulse rate of 100. (2 points)
What is the probable reason for the second admission?
What are the legal ramifications of this case?
Describe 3 areas of concern in IV therapy that can put a nurse at risk for litigation. (1 point)
Missy, an LPN, has been asked to administer a drug by IV push. She is uncertain whether or not this task falls within her scope of practice. Which are the proper resources to refer to for information related to her scope of practice? Select all that apply. (1 point)
Hospital and unit policies and procedures
The ordering physician
The CNA working with her
The hospital pharmacist
Nurse Practice Act
State Board of Nursing
A pediatric client is admitted to the unit with pneumonia. A peripheral IV is ordered. (2 points)
What equipment would you choose for this infusion and why?
What education would you provide the parents?
The nurse is inserting a peripheral IV catheter into Mr. Twinkle’s right arm. The client suddenly says, “That feels like there is an electrical shock going down my arm and into my fingers!” What should the nurse do first? (2 points)
Explain to the client that is a common response to having an IV inserted
Instruct the client to relax and take deep breaths
Pull the needle out slightly and then advance it again
Remove the needle from the client’s arm
Give rationale for your answer:
Explain at least 2 things that the RN could delegate to a CNA in the preparation of the venipuncture procedure for an elderly client. (1 point)
The nurse is caring for Mrs. Fellow on a medical unit. She was admitted with deep vein thrombosis (DVT). Admission orders include IV heparin 2,000 units per hour continually. (1 point)
If the heparin is available as 25,000 units in 500 ml of 5% dextrose in water, at what rate will the nurse set the infusion pump?
What med should available as an antidote?
How will the nurse know if the treatment for DVT is successful?
Give 2 therapeutic communication statements that the RN could use to ease the worry of the pediatric client whom must undergo venipuncture. (1 point)
Describe the consequences to a client if a nurse unintentionally punctures an artery for infusion therapy instead of venipuncture. (1 point)
Describe the rationale for using the smallest cannula possible for venipuncture. (1 point)
The use of laminar flow hoods in the pharmacy when preparing IV solutions: (Select all that apply-1 point)
May decrease airborne contaminants entering the IV solution
Will protect the pharmacist from exposure to all chemicals
Provides a constant, one-directional flow of filtered area on the work space
Should especially be used when preparing cytotoxic medications
Mr. Cummings, a client with delirium, is admitted to the hospital. His lab results were: Na 155, Cl 101, K 3.9, HCO3 21, BUN 88, glucose 99. Based on these results, which of the following nursing diagnoses are the most appropriate for this client? (1 point)
Imbalanced nutrition, less than body requirements
Impaired urinary elimination
Fluid volume deficit
Fluid volume excess
Self-care deficit: feeding
What are the two main different types of IV replacement fluid and describe the difference between the two different types of fluid? Give an example of both kinds of solutions. (2 points)
List three ways to prevent complications from occurring with IV therapy. (1 point)
An increased amount of circulating antidiuretic hormone will cause (increased/decreased) water retention. (1 point)
What is the normal serum level for potassium? ____________ and list 3 symptoms of hypokalemia. (1 point)
List 5 nursing interventions which would be effective with treatment of fluid volume deficit. (1 point)
Joseph, a young adult client, has been admitted to a medical unit with complaints of fever, vomiting and diarrhea. The nurse documents the nursing diagnosis of Fluid Volume Deficit on his care plan. Which of the following lab results would demonstrate an improvement in Joseph’s condition? (1 point)
Urine specific gravity 1.025, Hematocrit 44%, Sodium 140
Urine specific gravity 1.000, Hematocrit 37%, Sodium 133
Urine specific gravity 1.040, Hematocrit 55%, Sodium 156
When giving potassium infusions, the medication must be _____________, the concentration should not exceed ____________and should not be given at a rate that exceeds __________. _________monitoring should be done during potassium infusions. The most common client complaint during potassium infusion is _______________. If this occurs, the nurse should __________________________
What is biofilm and what are the implications of it in IV therapy?
List signs and symptoms that could be present in the following body systems during fluid volume excess and fluid volume deficit.
Fluid Volume Excess
Fluid Volume Deficit
Cardiovascular
Urinary
Gastrointestinal
Musculoskeletal
Neurosensory
Integumentary
Respiratory
What are the dangers of using D5W for hydration?
Describe 4 specialized nursing considerations related to safety for each of the following categories of clients regarding IV therapy:
Pediatric clients
Geriatric clients
If children require 20ml/kg/hr of IV fluid replacement for the first hour of initial management of fluid loss, how many ml/hr will the nurse set the pump at for a child weighing 14 pounds? Calculate ml/hr for the first hour, rounding to the nearest whole number.
Using scholarly resources and/or a state board of nursing website, please discuss the scope of practice for IV therapy for the LPN and the RN.
True or False Scalp veins do not contain valves, which allows for two-way flow of the blood.
True or False When inserting an IV into a scalp vein, aim the needle upward toward the top of the head.
True or False In the geriatric client, the veins in the hands are not the best choice at times for infusion therapy due to thinning of the skin and loss of subcutaneous tissue.
True or False Stabilization of the vein is a very important technique in successful IV insertion in the geriatric client.

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Ms. Y is a 44-year-old woman diagnosed with non-Hodgkin lymphoma (NHL) 3 months ago. She finished receiving her third of six chemotherapy courses 5 days ago. Yesterday morning, she was seen at her oncologist’s office for malaise, muscle weakness, and palpitations. She had splenomegaly on examination. A computed tomography (CT) scan of the abdomen showed metastatic disease in the liver and spleen. She is admitted to the hospital with progressive weakness.
Name 3 risk factors for lymphoma.
A.
B.
C.
Chart View
Comprehensive Metabolic Panel (CMP)
Na 139 mEq/L
K 6.3 mEq/L
Cl 96 mEq/L
CO2 28 mEq/L
Glucose 101 mg/dL
Blood urea nitrogen (BUN) 59 mg/dL
Creatinine 2.5 mg/dL
Ca 6.9 mg/dL
Total protein 5.4 g/dL
Albumin 2.8 g/dL
Phosphorus 4.9 mg/dL
Uric Acid 21 mg/dL
Total bilirubin 0.8 mg/dL
Alkaline phosphatase 172 units/L
Aspartate transaminase (AST) 254 units/L
Alanine transaminase (ALT) 74 units/L
Lactate dehydrogenase (LDH) 214 IU/L
Interpret Ms. Y’s admitting comprehensive metabolic panel results.
Based on the laboratory test results, which common oncologic emergency is Ms. Y experiencing?
Describe the pathophysiology of this condition.
What assessment findings related to this diagnosis would you expect in Ms. Y?
Complete Blood Count (CBC)
White blood cells (WBCs) 1500/mm3
Neutrophils 66%
Lymphocytes 16 %
Monocytes 15%
Eosinophils 5%
Hemoglobin (Hgb) 7.9 g/dL
Hematocrit (Hct) 22.4%
Platelets 21,000/mm3
Interpret the lab values above.
Name 3 additional problems for which Ms. Y is at risk.
What are your nursing priorities right now and why?
Medication Record
IV 0.9% normal saline at 150 mL/hr
100 mEq sodium bicarbonate (NaHCO3) in the first liter of the IV fluid
rasburicase 6 mg IV now
allopurinol 500 mg twice a day orally
furosemide 40 mg IVP now then every 6 hours
sodium polystyrene sulfonate (Kayexalate) 15 g orally every 6 hours
aluminum hydroxide 2 caps orally with meals
What is the expected outcome associated with each medication Ms. Y is receiving?
normal saline
NaHCO3
rasburicase
allopurinol
furosemide
Kayexalate
What are your nursing responsibilities when administering Kayexalate?
Discuss 2 major complications that could happen if Ms. Y’s abnormal laboratory test results (CMP results) will not be resolve?
A.
B.
Name 3 signs and symptoms for each of the following problems.
A. anemia
B. neutropenia
C. thrombocytopenia
List at least 7 independent nursing interventions that you would include based on the client’s abnormal laboratory test results.
A.
B.
C.
D.
E.
F.
G.
Comprehensive Metabolic Panel (CMP) day 2
Na 136 mEq/L
K 4.7 mEq/L
Cl 104 mEq/L
CO2 26 mEq/L
Glucose 110 mg/dL
Blood urea nitrogen (BUN) 36 mg/dL
Creatinine 2.1 mg/dL
Ca 7.9 units/L
Total protein 5.4 g/dL
Albumin 2.8 g/dL
Phosphorus 4.1 mg/dL
Uric Acid 2.0 mg/dL
Total bilirubin 1.0 mg/dL
Alkaline phosphatase 94 units/L
Aspartate transaminase (AST) 46 units/L
Alanine transaminase (ALT) 44 units/L
Lactate dehydrogenase (LDH) 222 IU/L
Interpret Ms. Y’s latest lab results by comparing it with the previous laboratory test results 24 hours ago.
If you think that the client’s condition is resolving, what other interventions would you include in her plan of care?
List at least 5 other oncologic emergencies and give at least two nursing interventions for each.
A.
B.
C.
D.
E.

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Question 25
The type of therapy typically indicated for individuals with chronic and significant suicidality and self-harm is known as which of the following?
Cognitive behavioral therapy (CBT) .
Trauma-focused CBT
.
Motivational interviewing
.
Dialectical-behavioral therapy
.
Question 26
The average time from the start of child mental health symptoms until a young person enters mental health treatment is which of the following?
A 4weeks-6 .
B 3months-6 .
C 1-2 years
.
D 8-10
years
Question 27
A general term for programs that teach and encourage skillful parent and caregiver responses to challenging child behaviors.
Motivational interviewing
.
Dialectical-behavioral therapy
.
Cognitive behavioral therapy (CBT) .
Behavioral management training .
Question 28
Nightmares and night terrors are associated with disorganization and arousal during which stage of sleep?
Stage1
.
Stage2
.
Stage3
.
Stage4
.
Question 29
The right to assent of dissent from treatment for a child or adolescent is reflected in which of the following American Academy of Child and Adolescent Psychiatry ethical issues?
Fidelity
.
Autonomy
.
Beneficence
.
Nonmaleficence
.
Question 30
In the event of a crisis in which the child is threatening to hurt himself, the first steps should include which of the following?
Address any acute safety concerns
.
Obtain any necessary professional assistance .
Develop a prevention plan for future crises .
A and B
.
Question 31
A 10-year-old child presents with developmentally inappropriate and persistent difficulty with inattention with symptoms which are interfering with academic goals and in social settings. This is consistent with which of the following diagnoses?
Conduct disorder
.
Autism spectrum disorder
.
Generalized anxiety disorder
.
Attention-deficit/hyperactivity disorder .
Question 32
A patient presents endorsing persistent low-grade (sub-acute) depression for the last several years, uncertain of when it started, thinks he has always been depressed but still goes through the motions. These symptoms are consistent with which of the following diagnoses?
Dysthymia
.
Cyclothymia
.
Major Depression, subacute, recurrent .
Bipolar II disorder
.
Question 33
Examples of atypical features in a patient with Major Depressive Episode include which of the following?
A Overeating and
oversleeping
Loss of appetite
.
Insomnia
.
Sleep walking
.
Question 34
Somnambulism is characterized by which of the following?
Waking from sleep/naps with vivid recall of intensely frightening dreams
.
A sleep-wake pattern out of synchrony with the desired sleep-wake schedule
.
Excessive daytime sleepiness or sleep attacks
. D Repeated episodes of rising from bed and walking about for between several minutesto a half hour during nocturnal sleep .
Question 35
A 15-year-old girl presents with symptoms that include restrictive eating and food avoidance, with a desire to avoid obesity, which persists despite negative consequences. This presentation is consistent with which of the following diagnoses?
Bulimia nervosa
.
Anorexia nervosa
.
Encopresis
. D Autism spectrum disorder .
Question 36
Which of the following antidepressants are approved by the FDA for treating depression in children ages 8-17?
Sertraline
.
Fluoxetine
.
Duloxetine
.
Fluvoxamine
.
Question 37
When assessing for substance abuse in an adolescent, the clinician should initially assess for which of the following?
Safety
.
Self medication
.
Substance tolerance .
Substance use disorder .
Question 38
Which of the following is consistent with what is known about prevalence of Bipolar I disorder?
Bipolar I Disorder is more prevalent in men
.
Bipolar I Disorder is more prevalent in women
.
Manic episodes are more prevalent in women.
.
Bipolar I Disorder has equal prevalence among men and women. .
Question 39
Which of the following is NOT consistent with the code of ethics for the nursing profession?
A code of ethics for the nursing profession informs every aspect of the nurse’s life. .
A code of ethics makes explicit the primary obligations of the nursingprofession.
.
A code of ethics addresses the values and ideals of the nursing profession. .
B and C only
.
Question 40
Which of the following is NOT consistent with what is known about anorexia nervosa?

Anorexia nervosa is more prevalent in males.
.
Anorexia nervosa is most frequent in developed countries
.
Anorexia nervosa is equally prevalent in males and females
. D Roughly half of patients with anorexia nervosa will not only diet but will also regularlyengage in binge and purge behaviors .
Question 41
The mental health practitioner realizes the following about using a behavioral health rating scale?
Rating scare are inherently imperfect.
.
Rating scales should never be the sole basis for making a diagnosis.
.
Behavioral health rating scales are an efficient tool to quickly diagnosis a patient. .
A and B
.
Question 42
When responding to a family member about the genetic factors related to mood disorders the APRN would share which of the following?
There is no evidence that genetics plays a role in mood disorders.
.
If one parent has a mood disorder the child has a 50% risk of developing a mood disorder. .
Bipolar I Disorder is typically the most common form of mood disorder in families of bipolar probands. .
Evidence from twin studies provides the most compelling data for the role of genetic factors in mood disorders. .
Question 43
Which of the following medications are approved by the FDA for treating OCD in children ages 6-17?
A
. Sertraline
B
. Fluoxetine
C
. Fluvoxamine
D
. Clomipramine
Question 44
Universal sleep hygiene would NOT include which of the following?
Getting adequate exercise
.
Avoid heavy meals before bedtime
.
Consistent bedtime and arousal time
. D Only go to bed when you are actually feeling sleepy .
Question 45
Which of the following is NOT consistent with pseudodementia seen in major depressive disorder?
Sudden onset
.
Diurnal variation
.
Confabulation
.
Can be coached and encouraged into remembering .
Question 46
When evaluating a child due to disruptive or aggressive behavior, which diagnostic category should be considered first?
Abuse
.
Conduct disorder
.
Communication disorder
.
Attention deficit/hyperactivity disorder .
Question 47
Which of the following may be symptoms of depression in children?
School phobia
.
Excessive clinging to parents
.
Preferring to spend time with friends fromschool .
A and B
.
Question 48
Which of the following would be consistent with ethical principles regarding relationships with patients in the ANA’s Code of Ethics for Nurses (Provision 1.2)?
The nurse must respect patient’s decisions. .
The nurse must support all patient choices. .
The nurse must agree with all patient choices. .
A and B only
.
Question 49
The domain of ethics concerning the nature of ethics and moral reasoning is known as which of the following?
A Metaethics
. B Normative ethics .
Applied ethics
.
Moral ethics
.
Question 50
A dissociation between the patient’s experience of sleeping and the objective polygraphy measures of sleep is known as which of the following?
A Sleep state misperception .
B Psychophysiological
.
insomnia
Persistent insomnia
.
Non-organic insomnia
.

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Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 5th Edition
Thyroiditis
Case Studies
The patient, a 23-year-old woman, has had a bout of flulike symptoms over the past few weeks. Most recently, she has become increasingly tired. She is taking birth control pills to control her menses. Her anterior neck became painful during the past few weeks. The physical examination results reveal that her thyroid is diffusely enlarged and mildly tender.
Studies Results
Routine laboratory tests Within normal limits (WNL)
Total thyroxine (T4), p. 497 8 mcg/dL (normal: 5-12 mcg /dL)
Free T4 0.5 ng/dL (normal: 0.8-2.7 ng/dL)
Free T4 index 0.4 ng/dL (normal: 0.8-2.4 ng/dL)
Triiodothyronine (T3), p. 506 52 ng/dL (normal: 70-205 ng/dL)
Thyroxine-binding globulin (TBG), p. 495 12 mg/dL (normal: 1.7-3.6 mg/dL)
Thyroid stimulating hormone (TSH), p. 486 32 microunits/mL (normal: 2-10 microunits/mL)
Thyroid scanning, p. 839 Enlarged gland; normal shape, position, and function of the thyroid gland. No areas of decreased or increased uptake
Thyroid ultrasound, p. 895 Enlarged gland; normal shape and position of the thyroid gland
Thyroid antibodies
Antithyroglobulin antibody, p. 102 1:250 (normal: titer <1:100) Antithyroid peroxidase antibody, p. 104 1:500 (normal: titer <1:100) Thyroid-stimulating immunoglobulins, p. 491 Negative Diagnostic Analysis Total T4 measures protein-bound and unbound T4. Because the patient was taking birth control pills, her TBG was elevated; therefore, her total T4 was normal. Free T4 and FT4 index tests measure unbound T4. When the free T4 and the FT4 index were measured, they were found to be low, indicating that the patient had hypothyroidism. The TSH level was elevated because of primary failure of the thyroid. The thyroid antibodies were elevated, indicating that the patient had Hashimoto thyroiditis. Her long-acting thyroid stimulator (LATS) levels were normal, discounting Graves disease as a cause of her diffusely enlarged thyroid. Her thyroid ultrasound and scan failed to show any localized, defined tumor. The patient was started on thyroid replacement therapy, and her TSH level returned to normal. Over the next few weeks, she felt markedly better. Her thyroid pain and tiredness disappeared. Critical Thinking Questions Why were the thyroid antibodies important in this patient's diagnosis? What symptoms might she experience if too much thyroid replacement medication were administered?

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1 Antigone represents those who:
a. They forgive the enemy.
b believe by unconditional faith.
c they don’t commit.
d take positions in life.
e they fear the state.
2 A trait of Cretan culture was:
a. his extreme pacifism.
b. ignorance of religion.
c. livestock issues.
d. seminomadism.
e live in small villages.
3. A trait of the Paleolithic era was:
a the appearance of the currency.
b semi-nomadic life.
c the development of pottery.
d the invention of the alphabet.
e advancement in jug painting.

4. A legacy of Rome was:
a. heliocentric science.
b. totemism.
c. the Pythagorean system.
d. satirical literature.
e. the sexagimal system.

5. A point of Greek culture was:
a. strict sexual morality.
b. abusive religious fanaticism.
c. ritual cannibalism.
d. social polygamy.
e. critical reflection.

6. A contribution of Greek culture to posterity was:
a. metallurgy.
b the bas-relief.
c. the drama.
d. zoolatry.
e. the goldsmith

7. How is the origin of evil, punishment and knowledge explained in the first three chapters of Genesis?

8. The Neolithic is a prehistoric period characterized by being an era:
a. industrial.
b. philosophical
c. villager
d. scientific.
e. pre-agricultural

9. What in your opinion are the principles of Socrates that we human beings of the 21st century should consider? Answer in light of the reading “Socrates and Greek philosophy”.

10. The reading “There are no stupid questions” by Carl Sagan begins by talking about:
a. primitive society.
b. Eskimo religion.
c. the discovery of Troy and Pompeii.
d. the inhabitants of the Renaissance.
e. the world wars.

11. Carl Sagan says that young people at his institute (University) are afraid to ask questions due to, among other things:
a. their religious fears.
b. who do not know the story.
c. the ignorance.
d. peer pressure.
e. They are only interested in music.

12. In the studies presented by Sagan, US students:
a. they were the best in all the sciences.
b. They showed that they knew more about the technology.
c. they lost in almost every order.
d. they won in science and mathematics.
e. they only won in art and music.

13. For Sagan, adult Americans:
a. they are the best in philosophy.
b. They have educational deficiencies.
c. dominate the field of astronomy.
d. They know a lot about physics.
e. everyone accepts Darwinism.

14. Carl Sagan highlights in the article:
a. the wisdom of spirit guides.
b. faith, tradition and authority.
c. the scientific method and experimentation.
d. the educational value of obedience.
e. religious culture based on inspired books.

15. We must improve, according to Sagan, through:

a. More budget for education.
b. support for banks and entrepreneurs.
c. strengthen military spending.
d. entertainment and festivals.
e. religious television programs.

16 Sagan says that ordinary people in the US:
a. They think science is hard.
b. They enjoy good knowledge of history.
c. They know a lot about other cultures.
d. they know quite a bit about the literature of Asia and Africa.
e. consider the paleontological field useless.

17 Sagan considers that it is necessary to stimulate:
a. more acknowledgment of the paranormal.
b. critical and skeptical thinking.
c. respect and observance of the Bible and the Koran.
d. the values of the nation’s founders.
e. reverence and submission to educators.

18 Sagan states that a good resource for better educational training is:
a. ask questions.
b. rigid and disciplined schools.
c. go to the wise men of the past.
d. memorization.
e. pressure the student.

19. During the Neolithic era it developed:
a. the patriarchy.
b. irreligiousness.
c. the matriarchy.
d. Gender equality.
e. the foundling

20. Oedipus deciphered the question from:
a. the Sphinx.
b. the jellyfish.
c. the Minotaur.
d. the Oracle.
e. the cyclops
21 Oedipus was a
a. abusive husband.
b. good question solver.
c. bad fighter.
d. mediocre son.
e. unjust king.

22 Oedipus was sentenced to:
a. exile.
b. torture.
c. hell.
d. leprosarium.
e. corporal punishment.

23 Oedipus finished:
a. devoured by a monster.
b. sacrificed to the gods.
c. in exile
d. committing suicide
e. killed in combat.

24 In the mythological story of Oedipus it was understood that human beings:
a. They ruled the gods.
b. they exercised free will and freedom.
c. they traced and determined their own lives.
d. They were controlled by fate.
e. They were despised by the divinities.

25I n the Oedipus legend it is understood that:
a. military revenge is legitimate.
b. the Oracle of Delphi is wrong.
c. incest is acceptable.
d. fate is inescapable.
e. the death of defenseless in understandable.

26. The Middle Ages emphasized the:
a. bestiality.
b. rationalism.
c. scientism.
d. animism.
e. theocentrism.

27. As a result of the Reformation and Counter-Reformation there were:
a. help of religions to new scientific ideas.
b. fanaticism and intolerance among Christians.
c. recognition and respect for so-called witches.
d. rise of medieval pagan ideas.
e. dialogue and understanding in Europe.

28 A characteristic of the Renaissance was:
a. the development of the sciences.
b. take the Middle Ages as a model.
c. rejection of antiquity.
d. the cult of reason.
e. the rise of the reliquary.

29.One cause of the religious crisis of the 16th century or Protestant Reformation was:
a. the interpretation of the Bible.
b. religious fanaticism.
c. theocentrism.
d. the conquest of the New World.
e. Nicolaus Copernicus thesis.

30 An idea of Martin Luther regarding religious doctrine was:
a. devotion to relics.
b. priestly celibacy.
c. the reduction of the sacraments.
d. works help salvation.
e. believe in all Catholicism.

31 During the Renaissance there were:
a. Few technical advances.
b. setback in inventions and travel.
c. peace and peaceful religious coexistence.
d. advance of feudalism, but commercial retreat.
e. intellectual and literary development.

32 During the Middle Ages it was believed in:
a. The science.
b. the technological.
c. The authorities.
d. zoolatry.
e. the animism.

33 The so-called Counter-Reformation saw the development of the Council of Trent where the Catholic Church established:
a. eliminate the catechism.
b. medieval theocentrism.
c. the Holy Office of the Inquisition.
d. the reduction of the sacraments to two.
e. acceptance of Lutheran ideas.

34 The Renaissance humanist Thomas More believed in:
a. Displace God from our life.
b. religious fanaticism.
c. the domination of one social class over another.
d. married life forever.
e. male dominance over female.

35 Theologian John Calvin posited:
a. devotion to science.
b. human predestination.
c. that God created the world and left.
d. the free will of the believer.
e. respect the opinion of others.

36 The order of the Society of Jesus was noted for emphasizing that its members, the Jesuits, stand out:
a. go back to the past and prevent the progress of knowledge.
b. to receive a careful intellectual formation.
c. for his combats against medieval heretics.
d. to dialogue and reach a consensus with the reformists.
e. in preventing science education from progressing.

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Instructions: Read the case study. Use the Rosdahl, Timby and drug books. For each question answered, cite the page number(s) of your reference(s). All questions apply to this case study. Your response should be brief and to the point. When asked to provide several answers, they should be listed in order of priority or significance. Do not assume information that is not provided.

Mr. Y is a 78-year old man who was born in Korea and moved to the US with his wife 50 years ago. Together, the couple opened a floral shop and ran the business for 40 years. Mrs. Y enjoyed watching her husband’s talent and love of nature come out in his flower arrangements.
When Mr. Y was in his late 60’s, he started having difficulty making his favorite flower arrangements. Their son also noticed Mr. Y misplacing tools, losing paper orders, and forgetting important pick-up times. At home, Mrs. Y noticed her husband having problems remembering recent events, and waking up at odd hours in the night thinking it was time to open the shop. Mr. Y was becoming irritable at home and at the shop.
When Mr. Y was 70 years old, the family decided to sell the business. Their healthcare providers confirmed that Mr. Y was presenting with early stage Alzheimer’s disease. The family decided that Mrs. Y would be appointed as her husband’s Power of Attorney for personal care and property. She continued to care for her husband at home.
When Mr. Y turned 75-years old, he was having increased difficulty remembering where things were in the house. He often woke his wife at odd hours of the night thinking it was time to get up and ready. When Mrs. Y reoriented her husband that it was still night-time, he would get confused an easily upset. Mr. Y was also becoming more physically weak, but did not perceive his limitations. He was home, forgetting where he had to go and which house was his.
Their son recognized that his mother was as happy as she used to be. She was constantly worrying about her husband’s increasing care needs, and could not enjoy activities she used to do. She was stressed and was not sleeping properly. With support from their healthcare providers the family decided that a long-term care setting would benefit Mr. Y and Mrs. Y’s well-being.
Admission to long-term care
At the admission conference, the long term care home’s social worker and charge nurse met Mr. Y and his family, and learned more about his history and preferences. His medical diagnosis includes moderate Alzheimer’s disease and osteoarthritis, with a history of urinary tract infections. Mr. Y hears well, uses reading glasses, and wears upper and lower dentures. Mr. Y also requires reminders to use his walker properly. Mrs. Y always prompted her husband for toileting, as well as when to eat and take medications. Mr. Y requires limited assistance from his wife during activities of daily living, such as dressing or transfers. As for his preferences, Mr. Y loves homemade Korean food, pastries, and warm drinks. He had always enjoyed baths in the evenings.
Mr. Y’s first week
During the first week in LTC, the staff noticed Mr. Y pacing the hallways, pushing locked doors, entering other residents’ rooms. When approached by the nursing staff, he had repetitive questions: “Who are you?”, “What do I do?”, “Where do I go?” Mr. Y required frequent reminders that this was his new home. During meals, Mr. Y ate little despite encouragement and staff offering assistance. During personal care such as changing, toileting and showering, Mr. Y kicked, scratched, grabbed and screamed at the staff. Two staff were required during these care activities.
Socially, Mr. Y actively participated in group craft activities and exercise classes when the therapists and staff coached him. During the times with no scheduled activities, Mr. Y paced the hallways and asked staff: “What do I do?”, “Where do I go?”
Mr. Y’s second week
At the end of the second week in the LTC, Mr. Y was no longer pacing the halls. He was often found napping in his room during the days. One afternoon, a staff nurse went into Mr. Y’s room and found him sleeping. She tried to gently wake Mr. Y, but he was not easy to arouse. She tried a second time and asked very loudly, “Mr. Y, it’s lunch time, are you ready to go?” Mr. Y slowly opened his eyes. The staff nurse repeated the question, and Mr. Y replied slowly, “Oh, I ate last week.” The staff nurse then asked “I know you had breakfast this morning, now it’s lunch time. Are you hungry?” Mr. Y paused and closed his eye. The staff nurse gently woke him again by rubbing his arm and repeated her question. Mr. Y slowly replied, “Yes, my wife is cooking, I will eat.” Together, they walked slowly to dining room.
In the dining room, Mr. Y stared out the window and did not answer the staff nurse when they asked him for his lunch preference. When approached a third time, Mr. Y rambled slowly in English and in Korean to the staff nurse. He continued to speak Korean to the staff nurse as they tried to assist him with his lunch, but he was unfocused and inattentive. He was unable to finish his meal because of his behavior. The staff were worried that he was not eating or drinking enough since admission.
When there were group activities, the therapists found it harder to encourage Mr. Y to attend and participate like he had been doing before. It took a lot of encouragement and assistance to have him attend. During the activity, he did not participate or sometimes fell asleep in the middle of the exercise or social program.
A few nights in a row, he was found wandering outside his bedroom without his walker. One time, he told the staff nurse, “Someone is looking for me.” The PSW reassured him that he is safe, and tried to direct him back to his room. But Mr. Y walked past the staff nurse and said, “I have to go to the bus stop.” After a few attempts, the staff nurse was able to direct Mr. Y to his room to sleep, and reoriented him to the use of the call bell. This behavior continued with increasing disorientation. The sleep disturbances resulted in Mr. Y being too drowsy in the mornings, and not able to eat any breakfast.
Although Mrs. Y was kept informed of her husband’s condition since admission to long-term care, it was not until her first visit during Mr. Y’s third week in long-term care when she realized how much her husband had changed. She was alarmed and asked the staff, “What is happening? What will be done for him? How can I help?”
Behavioral and psychological symptoms of dementia is a term used to describe the way a person with dementia expresses their unmet needs and presents symptoms of dementia. It is important to explore what is going on for the person. Looking at Mr. Y’s first week in long-term care:
He is wandering a lot, and staff has to re-orient him many times. What do you think is happening and why might he be reacting this way?
During Mr. Y’s personal care, what might be happening for him and why might he be reacting this way?
What other things can you do to explore underlying causes of a person’s behavioral and psychological symptoms of dementia?
A range of non-pharmacological approaches to care have been found to be effective at managing behavioral and psychological symptoms of dementia, but not all approaches are effective or appropriate for everyone. It is important to tailor a care plan to meet the person’s needs and preferences. What non-pharmacological approaches have you used to manage behavioral and psychological symptoms of dementia? Would you want to use these for Mr. Y?
Caring for people with dementia requires effective communication skills. Which strategies might work for Mr. Y? What are some communication strategies that have worked for you in the past?
There are several strategies to preserve Mr. Y’s abilities and promote living well with dementia.
What are some activities that long-term care staff can offer that you think Mr. Y will enjoy? Think of what he liked to do at home.
How can we promote Mr. Y’s social life?
It is important to promote a healthy lifestyle. How can we support Mr. Y’s nutrition?
How can we improve his quality of sleep?
Are there any issues surrounding Mr. Y’s safety? What can we do to make the environment safer?

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(BSc Adult Nursing-Foundation of Nursing)
Discuss the Nursing Assessment and Care Plan for Violet Smith? (1st person)
Consider the Activities of Daily Living (ADL’s) for Violet Smith. Identify 3 of her needs from your assessment and discuss what evidence-based care you plan to implement for her. Remember to consider Person/Family-Centred Care in your plan and include communication strategies and interprofessional collaboration opportunities.
Violet Smith Details below…..
Personal Profile : Violet Smith
Use this information in your assignment to develop your evidence-based description of care for Violet
GP Name
Dr. Glasgow Robinson
GP Address
111 London Road
Canterbury
CT2 5AF
Telephone No
01227 781111
Name : Mrs. Violet Smith – widow
Gender: Female
Age: 82
DoB: 31/12/1937
NHS Number: 4876334531
Address:
8 Tunis Court
Canterbury
CT3 1AH
Telephone: 01227 894545
Occupation : Retired but previously a librarian for 40 years
Next of Kin : Daughter – Eve : Mobile No. 07788617955
****** ********************************************************************

Violet Smith : Nursing Model based on Roper, Logan and Tierney.
Activity of living Assessment Actual or potential need
Maintaining a safe environment
Violet is an 82-year-old female who lives alone since the death of her husband, Stan, 2 years ago.
Violet now lives in a one bed roomed centrally heated flat. She down-sized after Stan died, having previously lived in the same home together for 35 years.
Violet has difficulty managing the stairs to her flat from the entrance – 6 steps with handrail. There is a rear entrance without steps but the path to access her back door is not well-lit and she does not like to use that entrance.
Violet sometimes feels dizzy when standing up. She has had 2 recent falls – one accidental due to tripping over her cat, but she cannot recall the reason for the second fall. Violet has a telecare pendant.
Violet has diagnosed hypertension – sitting BP 136/84 and standing BP 114/62. After 2 minutes her standing BP recovers to 128/76. Pulse 79.
Once standing Violet uses her husbands stick to steady herself when walking.
Trip hazard – There is a rug in front of Violets chair.
Violet sometimes forgets to take her medications (or does not remember if she has taken them). She takes a prescribed statin and two prescribed anti-hypertensives.
A
Communication
Violet wears reading glasses. Sometimes she forgets to take them off when mobilising so her vision can be blurry.
Violets hearing is good and she does not use aids.
Violet enjoys conversation and company and has a good sense of humour.
Violet is aware of some deterioration in her memory. She can find it difficult to recall things and sometimes forgets medications /conversations which she finds frustrating.
A
Breathing
Violet does not report any shortness of breath.
Self-ventilating – no relevant medications, oxygen or equipment required.
Respiration rate = 17 a minute.
Violet is a non-smoker.
P
Eating and
Drinking
When last recorded Violet weighed 8 stone 11 lbs. She has lost 4kgs in last 3 months – 60kgs to 56kgs.
Her BMI is 21
Violet says she has a lack of motivation to cook. Her daughter visits twice weekly and brings shopping.
Violet states she drinks 1-1.5 litres fluid (finds it difficult to drink more) and enjoys tea and squash (does not like water on its own). Violet enjoys a weekly Guinness.
Violet usually has cereal/toast breakfast and soup for lunch with main meal early evening – her favourite is steak & kidney pie.
She enjoys a chocolate biscuit and a slice of cake
Violet has top and bottom dentures and cleans these daily herself – they fit well and are not loose. Violets tongue is pink and moist and no signs of any furring or ulcers.
MUST risk assessment score – 1 (medium risk) You will discuss this tool in your assessment session.
A
Elimination
Violets bowels open every other day (type 4 Bristol stool chart) You will discuss this tool in your assessment session.
Violet experiences occasional stress incontinence and changes pads herself 1-2 times day (daughter purchases these from local supermarket).
Violet can mobilise to the toilet independently but sometimes struggles to get to the bathroom in time.
A
Washing and dressing
Violet does this independently but is finding this increasingly difficult (especially her legs and feet). She becomes tried and fatigued and the dexterity in her hands has deteriorated.
Violet uses a stool to sit on when she washes at the sink and a walk-in shower with perch stool. Violet uses E45 for dry skin but finds it difficult to get the lid off the pot.
Waterlow score 14. You will discuss this tool in your assessment session.
A
Controlling
temperature
Temp 36.8 centigrade. A routine urine sample has been tested – nothing abnormal detected. No other signs of clinical infection. Violet able to adjust clothing/ bed linen independently.
Violets flat is centrally heated and Violet likes to use fan in the summer months.
P
Mobilisation
Violet lives alone but has difficulty managing stairs to flat from entrance – 6 steps with handrail.
Violet finds it difficult to get up from her chair – sometimes takes up to 3 attempts and sometimes Violet feels dizzy when standing up.
Violet uses her husbands stick to steady herself when walking and does worry about falling/losing her balance.
A
Working and
Playing
Violet misses gardening after moving to smaller property.
Enjoys reading – biographies and romance.
Daughter (Eve) visits twice weekly usually a Tuesday and Saturday but also manages work and looking after her children.
Violets husband Stan died 2 years ago and Violet feels his loss and misses him greatly. This has exacerbated her feelings of loneliness at times.
Violet has stopped going to church due to fear of falling and wide-open space. She also finds it difficult to stand up and sit down with the congregation during a service.
A
Expressing sexuality
Violet has lost some of her identify since Stan died and social activity has reduced greatly, including not attending church and feeling part of her community. She feels lonely at times
Violet also is finding it difficult to meet all her personal hygiene needs including using the shower (sometimes she has a full wash using the basin), washing/drying her hair and apply her lipstick/makeup like she used to. Her daughter Eve does Violets hair when she visits and helps with the shower, although Violet feels embarrassed that her daughter has to shower me.
A
Sleeping
Violet has an interrupted sleep pattern and may get up once or twice to go to the toilet and then reads to get back to sleep. Often her mind drifts to Stan and she feels upset and unable then to go back to sleep or wakes early if she does. A
Death and dying
Violet talks about Stan dying and says ‘she is not frightened of dying as she will get to be with her Stan’ but would like to enjoy life more whilst she can. Violet believes in spirituality and life after death and misses her church community – the faith leader has offered to visit Violet at home.
P

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Comprehensive Health Assessment Form
(50 points)
Health History (5 pts total)
Biographical data: (1 pts)
No name or initial required
Age: __66____ Marital status: ____M _____ S _____Sep. __X__Cohab.
Birth date: _____06/10/1955_______ Number of dependents: ______2____________
Educational level: ___College Degree_________ Gender: _____F __X__ M _____Other
Occupation (current or, if retired, past): ________Investment Banker____________­­­­___
Ethnicity/nationality: __White/American___________________
Source of history (who gave you the information and how reliable is that person): ____________________Patient_____________________________________________
Present health history: (4 pts)
Current medical conditions/chronic illnesses:
Current medications:
Medication/food/environmental allergies:
Past health history: (10 pts total)
Childhood illnesses: Ask about history of mumps, chickenpox, rubella, ear infections, throat infections, pertussis, and asthma.
Hospitalizations/Surgeries: Include reason for hospitalization, year, and surgical procedures.
Accidents/injuries: Include head injuries with loss of consciousness, fractures, motor vehicle accidents, burns, and severe lacerations.
Major diseases or illnesses: Include heart problems, cancer, seizures, and any significant adult illnesses.
Immunizations (dates if known):
Tetanus _______ Diphtheria ________ Pertussis ________ Mumps ________
Rubella _______ Polio _____________ Hepatitis B ______ Influenza _______
Varicella ______ Other ____________________________________________
Recent travel/military services: Include travel within past year and recent and past military service.
Date of last examinations:
Physical examination _________ Vision ___________ Dental ___________
Family History (Genogram) (10 points)
Mother/Father/Siblings/Grandparents: include age (date of birth, if known), any major health issues, and, if indicated, cause and age at death Present as a genogram.
Review of Systems (12 points total) Be sure to ask about symptoms specifically.
General health status (1 pt): Ask about fatigue, pain, unexplained fever, night sweats, weakness, problems sleeping, and unexplained changes in weight.
Integumentary (1 pt):
Skin: Ask about change in skin color/texture, excessive bruising, itching, skin lesions, sores that do not heal, change in mole. Do you use sun screen? How much sun exposure do you experience?
Hair: Ask about changes in hair texture and recent hair loss.
Nails: Ask about changes in nail color and texture, splitting, and cracking.
HEENT (2 pts):
Head: Ask about headaches, recent head trauma, injury or surgery, history of concussion, dizziness, and loss of consciousness.
Neck: Ask about neck stiffness, neck pain, lymph node enlargement, and swelling or mass in the neck.
Eyes: Ask about change in vision, eye injury, itching, excessive tearing, discharge, pain, floaters, halos around lights, flashing lights, light sensitivity, and difficulty reading. Do you use corrective lenses (glasses or contact lenses)?
Ears: Ask about last hearing test, changes in hearing, ear pain, drainage, vertigo, recurrent ear infections, ringing in ears, excessive wax problems, use of hearing aids.
Nose, Nasopharynx, Sinuses: Ask about nasal discharge, frequent nosebleeds, nasal obstruction, snoring, postnasal drip, sneezing, allergies, use of recreational drugs, change in smell, sinus pain, sinus infections.
Mouth/Oropharynx: Ask about sore throats, mouth sores, bleeding gums, hoarseness, change voice quality, difficulty chewing or swallowing, change in taste, dentures and bridges.
Respiratory (1 pt):
Ask about frequent colds, pain with breathing, cough, coughing up blood, shortness of breath, wheezing, night sweats, last chest x-ray, PPD and results, and history of smoking.
Cardiovascular (1 pt.):
Ask about chest pain, palpitations, shortness of breath, edema, coldness of extremities, color changes in hands and feet, hair loss on legs, leg pain with activity, paresthesia, sores that do not heal, and EKG and results.
Breasts (1 pt.): (Remember men have breasts too)
Ask about breast masses or lumps, pain, nipple discharge, swelling, changes in appearance, cystic breast disease, breast cancer, breast surgery, and reduction/enlargement. Do you perform BSE (when and how)? Date of last clinical breast examination, and mammograms and results.
Gastrointestinal (1 pt.):
Ask about changes in appetite, heartburn, gastroesophageal reflux disease, pain, nausea/vomiting, vomiting blood, jaundice, change in bowel habits, diarrhea, constipation, flatus, last fecal occult blood test and colonoscopy and results.
Genitourinary (1 pt.):
Ask about pain on urination, burning, frequency, urgency, incontinence, hesitancy, changes in urine stream, flank pain, excessive urinary volume, decreased urinary volume, nocturia, and blood in urine.
Female/male reproductive (1 pt.):
Both: Ask about lesions, discharge, pain or masses, change in sex drive, infertility problems, history of STDs, knowledge of STD prevention, safe sex practices, and painful intercourse. Are you current involved in a sexual relationship? If yes, heterosexual, homosexual,, bisexual? Number of sexual partners in the last 3 months. Do you use birth control? If yes, method(s) used.
Female: Ask about menarche, description of cycle, LMP, painful menses, excessive bleeding, irregular menses, bleeding between periods, last Pap test and results, painful intercourse, pregnancies, live births, miscarriages, and abortions.
Male: Ask about prostate or scrotal problems, impotence or sterility, satisfaction with sexual performance, frequency and technique for TSE, and last prostate examination and results.
Musculoskeletal (1 pt.):
Ask about fractures, muscle pain, weakness, joint swelling, joint pain, stiffness, limitations in mobility, back pain, loss of height, and bone density scan and results.
Neurological (1 pt.): Ask about pain, fainting, seizures, changes in cognition, changes in memory, sensory deficits such as numbness, tingling and loss of sensation, problems with gait, balance, and coordination, tremor, and spasm.
Psychosocial Profile (10 pts)
Health practices and beliefs/self-care activities: Ask about type and frequency of exercise, type and frequency of self examination, oral hygiene practice (frequency of brushing/flossing), screening examinations (blood pressure, prostate, breast, glucose, etc.)
Nutritional patterns: Ask about daily intake (24 hour recall) and appetite.
Functional Ability: Ask if able to perform activities of daily living such as dressing, bathing, eating, toileting and instrumental activities of daily living like shopping, driving, cooking.
Sleep/rest patterns: Ask about number of hours of sleep per night, whether sleep is restful, naps, and use of sleep aids.
Personal habits (tobacco, alcohol, caffeine, and drugs): Ask about type, amount, and years used.
Environmental history: Identify environment as urban/rural, type of home (apartment, own home, condo)
Family/social relationships: Ask about significant others, individuals in home
Cultural/religious influences: Identify any cultural and religious influences on health.
Mental Health: Ask about anxiety, depression, irritability, stressful events, and personal coping strategies.
Now answer the question below: (3 pts)
Using the instructions below, identify 1 physical strength, 1 psychosocial/cognitive strength, and 1 weakness in either category. State why you think this to be true.
With the information you collected, you can begin developing an idea of a client’s weakness and strengths. What is a strength? This might be that a person’s nutritional status appears to be excellent. It may be that there is no impairment of mobility. They may have lots of friends with them so be socially active. What is a weakness? This might be that a person does have impaired mobility or perhaps imbalanced nutrition – more than or less than body requirements. It might be that they have a communication issue that you note or perhaps seem to have a depressed mood, seem alone/isolated.

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create a pathophysiology flow chart or diagram showing the clinical findings of a patient with osteoarthritis. Kindly refer to the case study attached below.
P.S. Pathophysiology should be in a flow chart or diagram form with explanation and kindly cite the reference
Reference: http://repository.stikesrspadgs.ac.id/71/1/100%20Case%20Studies%20in%20Pathophysiology-532hlm%20%28warna%20hanya%20cover%29.pdf
Case Study
Patient’s Chief Complaints
“I’m really having trouble getting around. My joints have been killing me. Knees and lower back are the worst. Other doctors won’t give me what I need to feel better.”
History of Present Illness
G.J. is a 71 yrs. old overweight woman who presents to the Family Practice Clinic for the first time complaining of a long history of bilateral knee discomfort that becomes worse when it rains and usually feels better when the weather is warm and dry. “My arthritis hasn’t improved a bit this summer though,” she states. Discomfort in the left knee is greater than in the right knee. She has also suffered from low back pain for many years, but recently it has become worse. She is having difficulty using the stairs in her home.
The patient had recently visited a rheumatologist who tried a variety of NSAIDs to help her with pain control. The medications gave her mild relief but also caused significant and intolerable stomach discomfort. Her pain was alleviated with oxycodone. However, when she showed increasing tolerance and began insisting on higher doses of the medication, the physician told her that she may need surgery and that he could not prescribe more oxycodone for her. She is now seeking medical care at the Family Practice Clinic.
Her knees started to get significantly more painful after she gained 20 pounds during the past nine months. Her joints are most stiff when she has been sitting or lying for some time and they tend to “loosen up” with activity. The patient has always been worried about osteoporosis because several family members have been diagnosed with the disease. However, no clinical manifestations of osteoporosis have developed.
Past Medical History
At age 23, the patient suffered a left knee injury in an MVA that did not require surgery. She also suffered a broken left hip 11 years ago when she fell on an icy sidewalk while visiting her sister in Michigan. Her hip seemed to have healed well as she has no significant symptoms that suggest hip joint involvement.
The patient has a 14-year history of OA, a 10-year history of HTN, a 4-year history of hypercholesterolemia, and a 4-year history of DM type 2. She also was hospitalized for an episode of diverticulitis two years ago. Her only surgery was a hysterectomy without oophorectomy 21 years ago. Menopause occurred at age 49, but she has never taken hormones.
Family History
• Father died from AMI at age 53
• Mother died from breast CA at age 80
• Patient has one brother, age 68, with HTN; one sister, age 74, who has severe allergies and has had two mitral valve replacements for rheumatic heart disease; and one sister, age 72, who also has OA
• Positive history of osteoporosis in mother and maternal grandmother
Social History
• Lives with her 72 yrs. old sister in a 3-story townhouse near the beach
• Exercises regularly in the pool and, sometimes, in the ocean, but can no longer walk long distances daily as she has done in the past
• Has a well-balanced diet with plenty of fresh fruits and vegetables, whole grains, and dairy products, but admits to eating “too many sweets”
• Has Medicare but no other health insurance
• Does not smoke and drinks 1-2 cocktails or glasses of white wine every evening with her meal
• Hobbies include quilting, baking, and teaching piano to children
Review of Systems
• Mild pain in right shoulder with lifting, carrying
• Low back pain with occasional “shooting pains” radiating to back of thigh
• Deep, aching pain in the pretibial area bilaterally and extending distally to the ankles and toes
• Patient denies any swollen, red, or hot joints, but notes “hard lumps” at the margins of the interphalangeal joints
• Patient denies numbness or weakness in her legs
• Patient denies pain or discomfort in her wrists and elbows
• Negative for headaches, neck stiffness, SOB, chest pains, urinary frequency or dysuria, constipation, diarrhea, nausea, loss of appetite, or significant changes in the appearance of her urine or stools
• Finger-stick blood glucose levels are usually around 180 mg/dL
• Occasional polyuria but no changes in vision
Medications
• Zolpidem 10 mg po Q HS PRN
• Atorvastatin 20 mg po Q HS
• Atenolol 25 mg po QD
• Lisinopril 40 mg po QD
• Metformin 250 mg po QD
• Glipizide 2.5 mg po QD
• Acetaminophen 1000 mg po TID
• High-potency multivitamin supplement with calcium, iron, and zinc po QD
• Calcium 600 mg with Vitamin D 125 IU supplement po BID with meals
Allergies
No known drug allergies
Physical Examination and Laboratory Tests
General
Alert, WDWN, overweight Caucasian female who appears slightly anxious but otherwise in NAD
Vital Signs
Patient Case Vital Signs
BP sitting, left arm 155/88 RR 15 and unlabored HT 5 ft-3 in
P 72 and regular T 98.8°F WT 164 lbs
Skin
Warm and dry with normal turgor
No petechiae, ecchymoses, or rash
Head, Eyes, Ears, Nose and Throat
NC/AT
PERRLA
Neck and Lymph Nodes
Neck supple
(-) evidence of thyromegaly, adenopathy, masses, JVD, or carotid bruits
Chest
Good chest excursion
Lungs CTA & P
Breast
Symmetric
No apparent masses, discharge, discoloration, or dimpling
Abdomen
Soft and non-tender without guarding
(+) BS
(-) organomegaly, bruits, and masses
Genitalia
Normal female genitalia
(+) mild vaginal atrophy
Normal anal sphincter tone
Stool heme-negative
Musculoskeletal/Extremities
Back with decreased flexion and extension
Back pain radiating to right buttock with straight right leg raising >60°
Full ROM at left shoulder, elbows, and ankles
Mild left hip discomfort with flexion >90° and with internal and external rotation >45°
Hips not tender to palpation
Bilateral knee crepitus and enlargement but more pronounced in left knee
Slight decrease in ROM and both Bouchard and Heberden nodes observed bilaterally during hand examination; no tenderness in finger joints
No redness, heat, or swelling in joints
Feet without breakdown, ulcers, erythema, or edema
Neurologic
Oriented X 3
Cranial nerves intact
Sensory exam normal and symmetric to pinprick and vibration
DTRs 2+ and equal bilaterally except for 1+ Achilles reflexes bilaterally
Strength 5/5 in both upper extremities; 4/5 in lower extremities
Gait slow but without specific deficits
Coordination WNL
No focal deficits
(-) Babinski bilaterally
Laboratory Blood Test Results
Patient Case Table 78.2 Laboratory BloodTest Results
Na
137 meq/L
MCV
87 fL
Protein, total
7.9 g/dL
K
4.4 meq/L
MCH
27.7 pg
Alb
4.2 g/dL
Cl
108 meq/L
MCHC
31.8 g/dL
Cholesterol
248 mg/dL
HCO3
23 meq/L
WBC
5.2 X 103/mm3
HbA1c
7.5%
BUN
7 mg/dL
Plt
239 X 103/mm3
Ca
8.7 mg/dL
Cr
0.6 mg/dL
AST
31 IU/L
PO4
2.9 mg/dL
Glu, fasting
241 mg/dL
ALT
19 IU/L
Mg
1.9 mg/dL
Hb
13.5 g/dL
Bilirubin, total
0.6 mg/dL
ESR
14 mm/hr
Hct
39.1%
Alk phos
97 IU/L
TSH
1.9 µU/mL
Urinalysis
Patient Case Table 78.3 Urinalysis
Appearance
Pale yellow, clear
Leukocyte esterase
Negative
Specific gravity
1.017
Nitrites
Negative
pH
6.3
Bacteria
Negative
WBC
0/HPF
Protein
Negative
RBC
0/HPF
Ketones
Negative
X-Rays
Lumbosacral spine
• Advanced degenerative changes with disk space narrowing and osteophyte formation at L3-4 and L4-5
• No evidence of compression fracture Left hip
• Mild-to-moderate degenerative changes with mild osteophytosis of femoral head
• Slight narrowing in joint space Right and left knees
• Moderate degenerative changes with joint space narrowing, subchondral sclerosis, and bone cysts
• No radiographic evidence of osteoporosis or joint effusions Right shoulder
• Mild degenerative changes with bone spurs at head of humerus
• Slight narrowing in joint space

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