CASE STUDY:

A 17-year-old male presents to the clinic with a chief complaint of pain in his right elbow. He says the pain is sharp, especially with pronation and supination.  He noticed the pain several weeks ago after his tennis team went to a regional competition. When he rests, the pain seems to go away. The pain is alleviated when he takes Naprosyn. No history of trauma or infection in the elbow. Past medical and social history non He is a junior at the local high school and just started taking tennis lessons 2 months ago and his coach is working with him on his backhand serve. A focused physical exam revealed point tenderness over the lateral epicondylitis and Lateral epicondylitis which increases with pronation and supination. The APRN diagnoses him with lateral epicondylitis and orders a wrist splint to prevent wrist flexion.

Question:

Why did the APRN feel a wrist splint would be helpful? What patient characteristics lead to this diagnosis.  

Case study:

A 61-year-old male complains of intermittent weakness and muscle fatigue that has progressively worsened over the past month. He was an internationally known extreme mountain climber but now he says he has difficulty in getting his morning paper. Initially, he thought his symptoms of profound leg weakness and fatigue were due to his age and history of injuries from mountain climbing.

Over the past few months, he also reports having noticed “blurriness” when working on his antique train collection or reading for long periods of time. He has developed an intermittent double vision that seems to be worse when reading at bedtime. He also reports an occasional “droopy” eyelid. Past medical and social history  Physical exam reveals weakness of right extraocular muscle (EOM) with repetition. There is positive nystagmus and symmetrical upper extremity weakness with fasciculations. Lower extremities within normal limits (WNL).   The APRN suspects the patient has myasthenia gravis (MG).

Question:

What is the underlying pathophysiology of Myasthenia gravis?  

Case study:

A 68-year-old man was brought to the emergency department by his family.

During his routine morning walk, he noticed a sudden onset of left facial numbness associated with a dull headache on the right posterior aspect of his head. He was staggering to the right side and feeling unsteady and nauseated, with no vomiting.

He telephoned his wife, who noticed his speech was slow and slurred, but there was no word-finding difficulty. His family immediately took him to the hospital.

There was a history of hypertension, hypercholesterolemia, ischemic heart disease (MI and PCI with a bare-metal stent in 2007), and probable transient ischemic attack (TIA) at the time of cardiac intervention. His medication included atenolol, ramipril, simvastatin, aspirin, and clopidogrel.

Within one hour, the patient’s symptoms had totally resolved. The diagnosis of transient ischemic attack was made, and the patient was discharged to home with instructions to contact his healthcare provider (HCP) for follow-up.

Question:

Why did the patient’s symptoms totally resolve?

Case STUDY:

A 57-year-old male construction worker comes to the clinic with a chief complaint of pain in his right hip. The pain has progressively gotten worse over the last 2 months and he has been having trouble sleeping. There is little pain in the morning, but he is a bit stiff.

The pain increases as the day wore on.  has taken acetaminophen without any relief but states that the ibuprofen does work a little bit. He is anxious since the hip pain has limited his ability to work and he is afraid that his boss will fire him if he cannot perform his usual duties.

There is no history of past trauma or infection in the joint. Past medical history noncontributory. Social history without history of alcohol, tobacco, or illicit drug use. A physical exam is remarkable for decreased range of motion of the right hip.

BMI 34 kg/radiographs in the office demonstrated asymmetrical joint space narrowing of the right hip with osteophyte formation. Several areas of the hip showed bone-on-bone contact with loss of the articular cartilage. The APRN tells the patient he has osteoarthritis (OA) and refers the patient to an orthopedist for evaluation of his need for a total hip replacement.

Question:

Describe how osteoarthritis develops and forms and distinguishes primary osteoarthritis from secondary arthritis.   

The “ideal” long-term care system base eligibility for services on functional needs rather than financial needs. Find the criteria for eligibility for Medicaid coverage for a nursing facility in your state (you can get the eligibility standards directly from the state or from a nursing facility).

Do you think they measure functional need vs. financial need? How close do they come to the “ideal” criteria? How would you change them if you could?