NSG6020 Advanced Health & Physical Assessment
Week 6 Aquifer Case Study
For this NSG6020 Advanced Health & Physical Assessment assignment, consider the following scenario;
You are working at a family medicine clinic with Dr. Hill. She tells you, “The next patient, Mr. Smith, is a 53-year-old male with a chief concern of swelling and pain in his left lower extremity.”
Before you go to see Mr. Smith, a quick review of the chart reveals that he has type 2 diabetes, obesity, hypertension, and hyperlipidemia. You note that he has not been to the office in the past six months, and it appears that he should be out of all of his medications.
When you enter the examination room, Mr. Smith, a middle-aged male, greets you from where he is sitting. You introduce yourself and ask him what brings him to the office today.
He replies, “It’s my left leg. The past four days it has been red, swollen, and painful—and it seems to be getting worse.”
You ask him to tell you more about this problem.
He says, “It began several days ago, and the swelling seems to be getting worse. It hurts all the time; it doesn’t even get better when I rest it. It seems to get a little worse when I move around. It hurts to walk as soon as I try to stand on it.” Now that you have a general sense of Mr. Smith’s issue, you ask more focused questions.
“Did you do anything to injure your foot?”
He replies, “I do not remember any injury, but there has been this sore on the bottom of my foot for several months. There’s nothing draining out of the sore and it doesn’t hurt, although my foot doesn’t have much feeling in it.”
“Before this happened, were you sitting down for a long time without getting up and using your legs, such as taking a long airplane trip; or have you been on bed rest?”
“I wish I could go somewhere on an airplane and get a good vacation, but I can’t afford anything like that. I haven’t been on bed rest. I’ve been pretty busy lately.”
“When was the last time you were in the office?”
“It has been a long time now because my daughter and new baby recently moved in with me and I have been trying to take care of the baby as well as keep my job as a bus driver,” he explains.
“Have you been taking your medication?”
He replies, “I have been out of my medication for several weeks now.”
After talking with Mr. Smith more, you discover:
Social History: Does not drink alcohol, but does smoke 1.5 packs of cigarettes daily, he is unmarried, and lives in public housing with his three children and one grandchild.
Review of Systems: No fever or chills, no chest pain, no shortness of breath, and no swelling of the right leg. You examine Mr. Smith and find:
Vital Signs: T 36.5 °C (97.8 °F), BP 140/90, HR 85, RR 12, O2 98%
Cardiovascular and lung exam: Unremarkable
Lower extremity exam:
Mr. Smith’s entire left leg is swollen, warm and erythematous. The measurement of the circumference of the largest left calf section is 3.5 cm larger than his right calf at the same location.
There is pitting edema. The leg is tender to the touch, especially along the distribution of the deep venous system.
Dorsalis pedis and posterior tibialis pulses are palpable on both feet. Digital capillary refill time is two seconds. Deep tendon reflexes are present (2+).
He has decreased sensation and is unable to determine the location of a monofilament test on either foot up to the ankle in a stocking distribution.
You note a 2 cm ulceration on the plantar surface of Mr. Smith’s left foot.
At this point, you excuse yourself to discuss your findings with Dr. Hill, assuring Mr. Smith you will return in a few moments.
Dr. Hill praises you, “Very nice clinical reasoning. It looks as though you have correctly narrowed your differential down to two primary diagnoses: cellulitis and deep venous thrombosis (DVT). It is important to make sure when crafting a differential for unilateral lower extremity swelling that DVT is always on that list as it’s a condition that can lead to death if missed. Let’s consider what type of information would be most helpful to obtain next.”
Dr. Hill asks:
“What test do you think we should order?”
You tell Dr. Hill, “I guess we should have a Doppler ultrasound done because it has the best predictive value for a DVT.”
“Suppose I told you that this test was relatively expensive and often overused,” Dr. Hill proposes, “Would that change your thinking?”
You respond, “Well you mentioned that the D-dimer test is highly sensitive. Perhaps we could rule out DVT by doing that one.”
“Very good thinking. That is precisely the appropriate role of that study. But, remember that the D-dimer test is best used to rule out a DVT if the pretest probability of having a DVT is relatively low.”
“Is there some way to estimate Mr. Smith’s pretest probability of having DVT?”
“I have read that no singular clinical finding is helpful in that,” you tell her.
“That is true,” Dr. Hill concurs. “But if we use several clinical findings, we may be able to do a better job of predicting pretest probability. I am speaking here of the Wells criteria.”
You conclude, “Given Mr. Smith’s high pretest probability of DVT, I don’t think I would trust a negative D-dimer result even with its high sensitivity. I think we have to get Mr. Smith a Doppler ultrasound instead.”
Dr. Hill agrees. “Ultrasonography is recommended as the initial test in a patient with high pretest probability.” And adds, “are there other diagnostic studies that you would order now?”
You and Dr. Hill return to Mr. Smith’s room together. After greeting him, Dr. Hill explains, “Mr. Smith, we have a good idea of what may be causing the issues with your leg. We would like to gather some more information by taking a blood sample and sending you over to radiology for a Doppler ultrasound so that we can determine the best course of treatment for you.”
After Mr. Smith assents to the plan, Dr. Hill washes her hands and asks to take a look at his leg. She agrees with your assessment.
She walks you through a diabetic foot examination:
On Mr. Smith’s exam, Dr. Hill finds 3 out of 10 sites imperceptible using the 10-gram monofilament test, indicating some loss of protective sensation.
She finds Mr. Smith’s dorsalis pedis and posterior tibialis pulses intact bilaterally.
She notes a 2 cm ulcer on the plantar surface of his foot, with some surrounding erythema, and callous formation. The ulcer is deep, including full skin thickness, down to muscles and ligaments, but no exposed tendons, or bony involvement, and there appears to be no abscess formation.
She finds that the skin on Mr. Smith’s feet is dry and his toenails are dystrophic and incurvated, demonstrating inappropriate self-care.
At the end of the diabetic foot exam, Dr. Hill turns to you and asks, “What do you think we should do about his foot ulcer?”
You admit, “I’m not sure about that. Would antibiotics help?”
“They would if his wound is infected, but first we should evaluate the grade of the ulcer,” Dr. Hill explains.
You and Dr. Hill determine that Mr. Smith’s foot ulcer does not require antibiotics at this time, but does require debridement, which you will address after he’s had his tests done. Mr. Smith has his blood drawn and a Doppler ultrasound performed.
A few hours later, you see that the results of the labs have returned:
Complete Blood Count:
|WBC||7.5 x103/μL||7.5 x109/L|
|Hgb||13.7 g/dL||137 g/L|
|Hemoglobin A1C||10.2 %||.102|
|Na||137 mEq/L||137 mmol/L|
|K||4.0 mEq/L||4.0 mmol/L|
|Cl||98 mEq/L||98 mmol/L|
|C02||25 mEq/L||25 mmol/L|
|BUN||18 mg/dL||6.3 mmol/L|
|Creatinine||1.0 mg/dL||88 mmol/L|
|Glucose||232 mg/dL||12.7 mmol/L|
Dr. Hill informs you, “I just received a call from the radiologist. It looks as if our suspicions were correct. Doppler ultrasound shows that Mr. Smith has a DVT in the femoral vein. So now the question is: What do we do about it?”
You respond, “Well he needs anticoagulation to prevent a pulmonary embolus (PE), right?”
“Right. His short-term risk of a PE is high, so we need to anticoagulate him right away.”
Dr. Hill calls Mr. Smith’s pharmacy and finds that his insurance will only cover dabigatran and does not cover any other DOAC. Unfortunately, insurance does not cover the necessary pre-treament parenteral agent enoxaparin (injectable low molecular weight heparin) without prior approval, which may take a few days to achieve. (It is late in the day when you are seeing him.) Dr. Hill asks you if you think he would be better managed in the hospital or as an outpatient.
After thinking about it for a minute you respond, “I don’t think it is acceptable to send him home if we can’t ensure that he will be able to get enoxaparin or one of the DOACs that can be used for monotherapy tonight. His day-to-day risk of a pulmonary embolus is too high. Also, I am worried about his ability to adhere to new complicated instructions, given that he has a busy home and work life and has not been able to prioritize his own care. He needs to have a plan for managing his medications and he has this foot ulcer that needs care. I think it would be best to stabilize him in the hospital and work on having a more supportive home environment.”
Dr. Hill replies, “Excellent. I agree that Mr. Smith will be best treated in the hospital. Let’s look into how we will do that.”
You and Dr. Hill decide to have Mr. Smith anticoagulated on LMWH because it doesn’t require laboratory testing and dosage titration and Mr. Smith may be more comfortable if he’s not hooked up to an IV.
Dr. Hill adds, “We only want to use low molecular weight heparin for a short term. After five days we will start dabigatran since he will need a longer course of anticoagulant therapy to reduce his risk of PE. In his case, his risk factors are not readily reversible, which will factor into our thinking about the duration of his treatment. If, for example, he had developed his DVT as a complication of surgery (a common and transient risk factor), we would have less cause for concern about his risk for recurrence of his DVT.”
Dr. Hill says, “Since we are planning on treating Mr. Smith in the hospital, one of the advantages of inpatient treatment is that we can get the wound team nurse to evaluate his ulcer and make some recommendations. While we have Mr. Smith in the hospital, are there other specialists or team members that we can involve to improve his health?”
You suggest, “What about an endocrinologist to help with diabetes management?”
“Now there’s an interesting thought. What do you think is complicating Mr. Smith’s glucose control?”
You contemplate this, “In thinking about his history, it seems that he has been nonadherent with his medication regimen, diet, exercise program, and his follow-up appointments for some time. He describes a stressful social situation at home with family and financial problems, as well as work-related stress.”
“How do you think an endocrinology consult will help with that?” Dr. Hill wants to know.
“I see your point,” you admit. “His problems in managing his chronic illness seem to be more social than medical.”
“That’s right.” Dr. Hill adds, “It’s possible that an endocrinology consult might be useful down the road, especially if he is brittle or otherwise difficult to control on routine medication, but we really have not had the opportunity to see if standard care will be successful because of his social factors.”
“So, I guess it might be better if we get some recommendations from a diabetes educator, a social worker and maybe even the Pharm D,” you suggest.
“Excellent! Ideally, we could all meet in a room and map out a plan for his care, but this isn’t practical in reality. Instead, our role, as the family clinician, is to assume responsibility for coordinating and directing his care and ensuring that everyone on the team is working toward the same goal.” Dr. Hill explains.
Dr. Hill explains to you the importance of testing for inherited thrombophilia, “Patients with DVT secondary to an inherited thrombophilia are treated differently than others.”
You and Dr. Hill return to Mr. Smith’s exam room to discuss your findings and recommendations with him.
Dr. Hill begins, “Mr. Smith, the reason your leg is so swollen and painful is that you have a blood clot in one of your veins. The good news is that we can treat this condition quite easily and quickly. We would like to admit you to the hospital to treat the blood clot that you have and start you on some medication which will keep you from getting another clot.”
“Hospitalization? I don’t have time to go into the hospital. I have a job and a family to take care of.”
“I understand that,” Dr. Hill assures him. “I hear you saying that it is very difficult to take care of yourself and your family, especially in this day and time, and I agree. But, if we don’t treat the blood clot in your leg, there’s a real risk that it will travel to your lungs and could kill you. You will only need to be in the hospital for a few days, and we would like to use this time to get your other health issues, like high blood pressure and diabetes under control. We also need to take care of that ulcer on your foot.”
“It sounds like I don’t have much of a choice. I guess I’ll have to go to the hospital. Why do I have a blood clot, anyway?” Mr. Smith wants to know.
You tell him, “Well, as we’ve discussed before, your smoking puts you at significant risk for a blood clot. Although you may not be aware, the fact that your body weight is higher than recommended also puts you at some risk of a blood clot. After we’ve addressed this immediate problem with your blood clot, we’d like to see you here at the clinic to revisit your smoking and your weight to see if we can work together to reduce your risk of another blood clot, as well as improve your health overall.”
Mr. Smith seems satisfied, and preparations are made for the hospital admission.
Several days have gone by and you and Dr. Hill are now rounding on your patients in the hospital. When you get to Mr. Smith, you tell Dr. Hill:
“This is Mr. Smith’s third day in the hospital. He says he is feeling better, the pain and swelling in his leg is improving. His temperature is 36.2 °C (97.2 °F), his pulse is 80 beats per minute, his respiratory rate is 16 breaths per minute, his blood pressure is 128/78 mmHg. On exam, his foot ulcer has some fresh granulation tissue on the wound edges. Labs include his fasting glucose this morning was 128 mg/dL (7.0 mmol/L). His CBC was normal and his platelets are stable from admission.”
Dr. Hill responds, “Good. I just got word from his pharmacy that the enoxaparin has now been approved by his insurance, so if he can inject himself for two more days, he can go home. We will need to arrange a close follow-up with visiting nurses and at our office, so he can continue his treatment for his diabetic foot ulcer.” You comment, “This all seems so much easier than it would have been if he were taking warfarin. How long would it take to get his INR to the therapeutic range if he were using warfarin?”
Dr. Hill tells you, “It varies a lot from person to person, but it commonly takes at least five days for a patient’s INR to get above 2.0. When starting it, you have to balance speed with the risk of overshooting his INR goal and ending up increasing his risk of bleeding by making him supratherapeutic. It is good to consider warfarin dosing since it is still commonly used. It is a very effective medication, but it can be dangerous as well.”
“What do you think we should do next?” Dr. Hill wants to know.
After contemplating this for a moment, you conclude, “Since his insurance has now approved the prior authorization for 2 days of enoxaparin he can finish the pretreatment phase at home. He has been on enoxaparin for three days now. My understanding is that he needs to be on enoxaparin for 5 days and then he can begin the dabigatran. He will need to be able to give himself the enoxaparin at home for 2 days and then be able to start the oral dabigatran about 12 hours after his last dose of enoxaparin. His floor nurse has been showing him how to give the injections, so I think he will be able to do it. He said he doesn’t like it very much, but he would do it if he has to.”
You continue, “He’s back on his regular medications which have improved his blood pressure and glucose. The foot ulcer has been debrided and is getting better. There doesn’t seem to be much more for us to do in the hospital, so I think he might be ready to go home later today.”
“I agree,” Dr. Hill replies. “What type of arrangements will he need at home?”
“Home health should be able to manage his wound. I would think with that and close follow-up in the office, he should do well,” you predict. “We also need to make sure he understands the timing of the enoxaparin and transition over to the dabigatran, and that he knows where to pick up both his medications. You also remind Dr. Hill that Mr. Smith’s obesity and smoking still pose tremendous risks to his health and that in future visits to the clinic, he should be counseled regarding weight loss and smoking cessation as well as managed for hypertension, hyperlipidemia, and diabetes.
NSG6020 Advanced Health & Physical Assessment Assignment
Complete only the History, Physical Exam, and Assessment sections of the Aquifer virtual case: Family Medicine 07: 53-year-old male with leg swelling.
You are required to answer all the NSG6020 Advanced Health & Physical Assessment DISCUSSION QUESTIONS listed below in each domain.
1a) Identify two (2) additional questions that were not asked in the case study and should have been?
1b) Explain your rationale for asking these two additional questions.
1c) Describe what the two (2) additional questions might reveal about the patient’s health.
DOMAIN: PHYSICAL EXAM
For each system examined in this case;
2a) Explain the reason the provider examined each system.
2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what exam findings could be abnormal.
2c) Describe the normal findings for each system.
2d) Identify the various diagnostic instruments you would need to use to examine this patient.
DOMAIN: ASSESSMENT (Medical Diagnosis)
Discuss the pathophysiology of the:
3a) Diagnosis and,
3b) Each Differential Diagnosis
3c) If it is a Wellness, type ‘Not Applicable
DOMAIN: LABORATORY & DIAGNOSTIC TESTS
Discuss the following:
4a) What labs should be ordered in the case?
4b) Discuss what lab results would be abnormal.
4c) Discuss what the abnormal lab values indicate.
4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.
4e) If this is a wellness visit, discuss what the U.S. Preventive Taskforce recommends for patients in this age group.