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Need a well organized write up School work 3 Pathophysiology Assignment
Endocrine Case Study Read the 3-part case study details below and answer the questions under each part.  Part 1: – The Case Timothy was always an active little boy, and was a great player for his Little League team at the age of 12. For the first year or so, Tim had no trouble catching balls and running bases. He was doing such a good job that he was even promoted to the next division. Unfortunately, this is also about the time that his mother started to notice that something wasn’t quite right with Timothy. At age 14, Tim started to have trouble with his coordination and was slower in practice. His mother wasn’t sure if maybe he was just getting bored with playing. His coach had no choice but to place him on the bench, he just wasn’t keeping up. He started to grow rapidly, and complained about pain in his joints. Family members just chalked it off to “growing pains.” Teachers observed that Tim seemed withdrawn, and even his grades began to slip. In junior high, many of the other boys were showing an interest in girls, but not Tim, he just became more introverted. By the time Tim entered high school, he was very tall for his age. At 6’2”, Tim weighed 155 pounds and wore size 13 shoes. Some of the kids teased him and called him “stringbean.” Even after Tim actively tried to put on weight and muscle mass by going to the gym after school, he just couldn’t seem to gain a pound. Tim’s grades were still not good, and he said he always felt anxious and jittery in school. Tim would often stay home because he felt sick to his stomach, though his mom thought that some of his symptoms might be due to being overwhelmed with his schoolwork. His mother finally decided to take Tim to the doctor to see if there was anything physically wrong with him. Dr. Chapman made some initial observations and asked Tim about his symptoms. He decided to check Tim’s blood to see if his hormone levels were in the normal range. He first focused on the thyroid, since that is the gland often associated with metabolism. List Tim’s symptoms and identify the organ system (or specific organ) associated with those symptoms. (Your may need to reference other materials to identify associated organs and systems.) Where is the thyroid? Why did the doctor want to focus on the thyroid? The doctor also decides to check on Timothy’s cortisol levels. What gland(s) produce cortisol? Part 2: – Test Results The doctor returned to show Timothy the results of his tests. Hormone levels were checked for Thyroid Stimulating Hormone, Thyroxine (T4), and Tri-iodothyronine (T3). TSH (mIU/L) T3 (ng/ml) T4 (ug/dl) Cortisol (ug/dl) Normal Low 0.4 0.8 4.5 3 Normal High 4.2 2.0 12.5 10 Timothy 0.45 2.6 13.2 9.8 Dr. Chapman shook his head at the results, clearly he was puzzled by some of the numbers. “It looks like you may have a condition called hyperthyroidism. We are going to need to get your TSH numbers higher to correct the problem.” Timothy looked at the chart and remembered something his biology teacher had told him. “Doesn’t the word ‘hyper’ mean ‘more’. Why would you want to make the TSH numbers higher if I already have too high levels of T3 and T4.” Dr. Chapman seemed impressed that he knew this and attempted to explain. “The whole system is part of a feedback loop with your pituitary gland.” The doctor sketched a quick diagram on the whiteboard in his office. “First, your pituitary senses the level of thyroid hormone in your blood, if the amount is low, then it releases Thyroid Stimulating Hormone to stimulate the thyroid to release more thyroid hormone. Basically, the pituitary is attempting to return the system to a normal functioning. 0 Timothy looked a the diagram and nodded. The doctor continued, “If your thyroid is overactive and producing too much hormone, then the pituitary senses this and slows or shuts down the production of TSH.” The doctor started writing a prescription. “This drug will suppress your thyroid and hopefully, your pituitary will notice the levels have dropped and will start producing more TSH to get you into the normal range.” Which hormones would be considered in the high range? What gland produces these hormones? Which hormones would be considered low? What gland produces these hormones The doctor didn’t mention cortisol, but it should also follow a similar feedback loop. Sketch a feedback loop that includes the hypothalamus, pituitary, adrenal glands, and cortisol. Part 3: – Symptoms Returned Timothy filled his prescription and for several years, his symptoms were alleviated. When he was 28 years old, two years after getting married, he started noticing other problems. Anxiety levels were extreme and he had gained so much weight he was almost 250 pounds. His wife wanted to have children, but she had not yet gotten pregnant. Tim wondered if maybe his medication needed adjustment, so he returned to Dr. Chapman. Dr. Chapman also noted that Timothy had very sparse body hair, so he also checked Tim’s testosterone levels and ran a battery of tests to see his other hormone levels. When the results came in, Dr. Chapman had some frightening news for Timothy. “Your hormone levels are all over the place,” He said. “Levels of testosterone are extremely low, which might be why you are having trouble conceiving. Your thyroid hormones are borderline low, but that could be due to medication. Your cortisol levels are off the chart though. This doesn’t look like it’s just a problem with your thyroid. I want to check your pituitary gland.” 0 Timothy frowned. “Isn’t that in my brain?” Dr. Chapman nodded. “A simple MRI should tell us if there is anything abnormal.” The results of Timothy’s MRI showed a mass on his pituitary gland and no major problems with the thyroid. Could Dr. Chapman have gotten the diagnosis wrong years ago? The new symptoms all indicated that a tumor had put pressure on the pituitary and disrupted its functions. Tim was referred to a hospital in Wisconsin, where they used radiation to destroy the pituitary and any tumor associated with it. 0 0 Why would a tumor on the pituitary gland affect the thyroid gland and also Tim’s levels of testosterone? The pituitary gland is called the “master gland.” What other endocrine glands would have been affected by its malfunction? Dr. Chapman suggested that Tim take a regimen of Human Chorionic Gonadotropin (HCG), which is analogous to luteinizing Hormone (LH) which is produced in the pituitary. Why would he recommend this? What problem will could this potentially solve for Tim? Do you think the original diagnosis was wrong? Why or why not? Neurologic System Case Study Read the details of each of the 5 cases presented below and answer the questions that follow each case.  Case 1: It was very dark as Carol walked home from the library. She was thinking about tomorrow’s test when she heard heavy breathing and then felt a strong hand on her shoulder. She turned and stared into the terrifying eyes of a huge man holding a chain saw. Without thinking, she swung her book bag with all her might, hit the enormous man in his stomach, knocked the breath out of him, and saw him double over. Carol ran home faster than she had ever run before. Her roommate couldn’t believe that 5 foot 1, 98 pound Carol had the strength to knock out the man’s breath and speed on home. When Carol first got home, her heart was pounding, her breathing was rapid, her nerves were on edge, she was sweating, and her mouth was dry. It was not until several hours later that Carol had calmed down enough to go to sleep. Which part of Carol’s nervous system gave her the “get up and go” and the strength to knock out the man’s breath and run home faster than the wind? What are some other functions of the part you listed in question 1 above? Which part of Carol’s nervous system helped calm down her body? What are some other functions of the part you listed in question 2 above? Case 2: Sharon has never told anyone her most secret fear. She’s terrified that she is part crazy because of things that happen to her. Sometimes she has terrible sexual desires that she can just barely restrain. Sometimes she goes from restaurant to restaurant and eats 4-8 meals a day. Sometimes she goes to a water fountain and drinks water for 15 minutes straight. Sometimes she feels tremendous love for her boyfriend and then, without warning, hates his guts. Sometimes she is happy and then suddenly becomes angry. There is a tumor growing in Sharon’s brain that is causing all of these strange behaviors. Where is the tumor growing in her brain? Name 3 behaviors regulated by that part? Name the evolutionary, very old brain system of which this brain part is part of? Case 3: From the time that she was a little girl, Marci had epileptic seizures. However, when she was young, the seizures occurred infrequently because drugs controlled them. As she grew older, the seizures became worse and the drugs no longer worked. By the time she was 21, she was having five to six major seizures a day. During a major seizure, Marci would fall to the floor, become unconscious, and her arms and legs would move in violent spastic motions. Many times her limbs were sprained and bruised. After the seizures, she would have no memory of what happened, and she usually felt very drowsy. Because the seizures were so frequent and so bad and drugs did not work, she chose to have a radical brain surgery called a split- brain operation. After the split-brain operation, Marci’s seizures were greatly reduced. What part of Marci’s brain did the neurosurgeon cut to produce a split-brain? What is the function of the part that was cut? Which hemisphere of the brain has superior language skills? Which hemisphere of the brain has superior mathematical skills? Which hemisphere of the brain is better at recognizing faces? Case 4: At eight o’clock on a Saturday night in Las Vegas, Bruno was waiting in the big hall and heard the crowd cheer when his name was announced. He walked down the aisle, climbed into the ring, and raised his gloved hands t.o greet the crown. For about two hours of his time, Bruno was going to be paid five million dollars. Bruno had earned a reputation as being fast and strong and was likely to be the next heavy-weight- boxing champion. In the first two rounds, his punches matched his reputation. In the middle of the third round, Bruno caught an unexpected vicious punch that snapped his head back. Before he knew what hit him, Bruno was lying on the mat, unconscious. Bruno never regained consciousness and remained in a coma. Now, many months later, Bruno’s chances of coming out of the coma are very small because one part of his brain was damaged by the knockout punch. What part of Bruno’s brain did the knockout punch damage? What is the function of this part of the brain? Where is it located? Case 5: Although Michelle is usually smiley and happy, some very weird things have happened to her this week that cause her to be a little concerned. On Monday, she was sitting in her art class watching a video when she suddenly could not see and discovered that she was completely blind. On Tuesday, she was practicing the violin when she realized that she couldn’t hear anything and was totally deaf. On Wednesday, now blind and deaf, she was in the cafeteria eating a pizza when she realized that she could not taste anything and had lost all sense of taste. By Thursday Michelle was getting a little concerned about how her life was going and what could happen next. She pinched herself to make sure that she was all right discovered that she couldn’t feel a thing. In just four days, she had lost her ability to see, hear, taste and feel. She remembered having some really bad weeks but nothing like this one. What part of Michelle’s brain was being destroyed by a tumor? What is the function of this part of the brain? Pulmonary System Case Study History A 65 years old former garage mechanic presents with a chief complaint of increased shortness of breath and a change in the quantity and color of his sputum for the past week. The sputum is usually scant and clear. However, recently it has become yellow and continues all day. He has had trouble raising sputum in the past year. He has become progressively short of breath over the last five years. He is now dyspneic at rest. He denies asthma, childhood respiratory problems, allergies and any occupational exposures. Physical Examination Obvious respiratory distress with prominent use of accessory muscles. Temperature 99.5; Blood pressure 140/90; pulse 110; respiratory rate 28. Head/neck reveal distended neck veins throughout expiration. Chest reveals increased A-P diameter; reduced chest wall excursion; lungs hyperresonant to percussion; diaphragms low and immobile; auscultation reveals a prolonged expiratory phase with diminished breath sounds and generalized rhonchi. Heart reveals PMI in epigastrium; heart sounds distant with regular rhythm and no murmurs. Extremities reveal trace pitting edema of the lower extremities. Chest x-ray reveals hyperinflation of lungs with an increase in the retrosternal space; low, flattened diaphragms; hyperlucent lung fields with paucity of vascular markings in the periphery but prominent hila and narrow heart silhouette. EKG reveals low voltage; right axis; peaked P waves and clockwise rotation. Laboratory reveals WBC 8,500 with normal differential and Hgb 14.7 gm. ABG’s: PFT 0100 (RA) 0300 (2 LPM) 0800 (2 LPM) 0800 (RA) Ph 7.38 7.37 7.42 7.42 Pa02 44 60 62 60 PaC02 58 63 44 36 HC03 (calc) 31 32 30 24 Normal: Ph 7.40+0.05; Pa02 80+10; PaC02 40+4; HCO2 24+2 Questions 1. What type of acid-base disturbance occurred in the Emergency Room? 2. What is the PA02? 3. What is the A-a gradient and what does it tell you? 4. Give at least two mechanisms of hypoxemia in this situation. 5. What does the elevated HCO3 tell you? Spirometry revealed the following: FEV1 at 0100=0.5 L (pred 2.9 L); at 0800=0.7 L. FVC at 0100=Unobt. (pred 3.9 L); at 0800=1.7 L. Hospital Course Arterial blood gases are drawn in the Emergency Room and oxygen (2 LPM) by nasal prongs is started.  Gases are repeated at 0300. You commence bronchodilators and begin trimethoprim/sulfamethoxazole. A gram stain of sputum reveals many PMN’s and some alveolar macrophages. At 0800, the patient feels better, can raise some sputum and is able to sleep. 6. Why begin trimethoprim/sulfamethoxazole? What are the most common pathogens in acute exacerbations of chronic bronchitis? 7. Why did the PaC02 increase at 0300? Should any therapy be altered to diminish the hypercapnia? Should the patient be intubated? 8. Note that the hypoxemia originally presented is easily corrected. What does this suggest as the mechanism of the hypoxemia? A review of old records reveal the followings: PFT 1978 1980 1983 FEV1 1.3 L 1.1 L 0.82 L (pred 2.9 L) FVC 3.0 2.9 1.96 (pred 3.95 L) RV 3.1 3.4 5.0 (pred 1.6 L) TLC 6.1 6.9 6.9 (pred 5.57 L) DCO 10 ml/min/mmHg 20 (pred 20)   9. How does this patient’s average yearly decline in FEV1 compare to the normal decline? 10. What do the PFT’s say about the relationship of FVC to RV and TLC? 11. Is this patient more like the classic pink puffer (type A) or blue bloater (type B) with COPD? What are the differences in lung physiology between these extremes? 12. What are the mechanisms of slowing of forced expiration in emphysema? Chronic bronchitis? Asthma? 13. What is the driving pressure in terms of Palv, Pel and Ppl? What occurs in emphysema? Explain how this affects forced expiration. 14. Which portion of the expiratory flow-volume curve is effort dependent? Effort independent? 15. Why is the thorax expanded in emphysema? 16. What is the diffusing capacity of carbon dioxide (DCO) in pure chronic bronchitis? Asthma? Integumentary System Case Study Norma is a 32-year-old physical therapist working in a major hospital, where she evaluates patients and assists with their therapy. Norma works with a wide variety of patients whose disorders include skin rashes, wounds requiring debridement, and various infectious diseases that call for isolation and the use of protective clothing. Recently Norma’s hands have become red and slightly edematous (swollen). She has also noticed that the elastic in some garments is irritating her skin. At first, Norma attributes the irritation to the frequent hand-washing and clothing changes necessitated by her increased patient load. However, over the next few weeks, Norma notices that her hands are not improving. In fact, she is developing bullae and vesicles on her hands and at places where elastic touches her skin. Also, she is experiencing marked pruritis. Norma makes an appointment to visit her physician the following Monday. Over the weekend, the itching decreases and the rash dissipates. After taking a history, the physician tells Norma that he thinks she may be coming into contact with something she is allergic to. He recommends skin scrapings and a patch test for some common allergies. Norma agrees, and a patch test is scheduled for the next day. Results of the patch test indicate that Norma has developed an allergy to latex. Her physician advises her to avoid touching latex, and if she does accidentally come into contact with it or if a rash develops, to apply gauze dipped in water to the lesions 4 to 6 times a day for 30 minutes each time. He tells Norma that if blisters form, she can drain them, but she must not remove the tops of the blisters. If blisters are not present, she may use a topical corticosteroid. Finally, the physician tells her she may take antihistamines to relieve the irritation, and he mentions that latex allergies sometimes cross-react with proteins in various fruits, so she should be aware of the possibility of experiencing new food allergies. Based on this case study and other information in this chapter, answer the following questions. 1. What risk factors are present in Norma’s case? What symptoms does she have? What signs does she exhibit? 2. If Norma’s doctor suspects contact dermatitis, why does he take skin scrapings? 3. Given Norma’s occupation, why is it especially important that she not remove the tops of the blisters? 4. A few weeks after her diagnosis, Norma attends a party where she eats some avocado dip. Her lips tingle slightly after eating it, but she dismisses this. A month later, eating avocados at home, her lips tingle more intensely and her tongue becomes somewhat swollen. What relationship might this have to her latex allergy? What should Norma do about it? 5. How would the patch test distinguish between a latex allergy and other possible allergies? 6. Athletes who use anabolic steroids often experience increased acne. Explain why. 7. Why is the control of pruritis so important in curing skin diseases? Musculoskeletal System Case Study M.S., a 72-year-old white woman, comes to your clinic for a complete physical examination. She has not been to a provider for 11 years because “I don’t like doctors.” Her only complaint today is “pain in my upper back.” She describes the pain as sharp and knifelike. The pain began approximately 3 weeks ago when she was getting out of bed in the morning and hasn’t changed at all. M.S. rates her pain as 6 on a 0- to 10-point pain scale and says the pain decreases to 3 or 4 after taking “a couple of ibuprofen.” She denies recent falls or trauma. M.S. admits she needs to quit smoking and start exercising but states, “I don’t have the energy to exercise, and besides, I’ve always been thin.” She has smoked one to two packs of cigarettes per day since she was 17 years old. Her last blood work was 11 years ago, and she can’t remember the results. She went through menopause at the age of 47 and has never taken hormone replacement therapy. The physical exam was unremarkable other than moderate tenderness to deep palpation over the spinous process at T7. No masses or tenderness to the tissue surrounded the tender spot. No visible masses, skin changes, or erythema were noted. Her neurologic exam is intact, and no muscle wasting is noted.  1. An x-ray examination of the thoracic spine reveals osteopenic changes at T7. What does this result mean?  2. The physician suspects osteoporosis. List seven risk factors associated with osteoporosis. 3. Which of the seven risk factors listed above are specific to M.S.? M.S. has never had an osteoporosis screening. She confides that her mother and grandmother were diagnosed with osteoporosis when they were in their early 50s.  4. What diagnostic test is most commonly used to diagnose osteoporosis?  5. M.S.’s diagnostic test revealed a bone density T-score of –2.7. How will this be interpreted?  6. M.S. receives a prescription for alendronate (Fosamax) 70mg/week. What instructions are appropriate to give as you provide patient teaching to M.S. about this drug?  7. M.S. is also instructed to take a calcium plus vitamin D supplement. She asks, “If I am taking the osteoporosis pill, won’t that be enough?” How do you answer her?  8. What nonpharmacologic interventions will you teach M.S. to prevent further bone loss? M.S. seems overwhelmed and says, “I cannot possibly stop smoking and lose weight and exercise all at the same time.”  9. You encourage M.S. to start working on one problem at a time. Which problem should M.S. attempt first? Renal System Case Study The patient is a 41 year-old male who has a longstanding history of hypertension and diabetes and presents with a complaint of pruritis, lethargy, lower extremity edema, nausea and emesis. He denies any other medical illnesses. On physical exam the patient is a well-developed, well-nourished male in moderate distress. Blood pressure 180/110, pulse 80, respirations 24 and he was afebrile. Body weight 76.5 kg. HEENT was remarkable for fundoscopic findings of A-V nicking and copper wire changes consistent with hypertensive injury. Cardiac exam had an S1, S2 and S4. The remainder of the exam was remarkable for 2+ lower extremity edema and superficial excoriations of his skin from scratching. Laboratory Data Chemistry  Normal Values  Urinalysis Sodium  133  136-146 mmol/L  pH 6.0 Specific gravity 1.010 Protein 1+ Glucose negative Acetone negative Occult blood negative Bile negative Waxy casts             Potassium  6.2  3.5-5.3 mmol/L  Chloride  100  98-108 mmol/L  Total CO2  15  23-27 mmol/L  BUN  170  7-22 mg/dl  Creatinine  16.0  0.7-1.5 mg/dl  Glucose  108  70-110 mg/dl  Calcium  7.2  8.9-10.3 mg/dl  Phosphorus  10.5  2.6-6.4 mg/dl Alkaline Phosphatase  306  30-110 IU/L Parathyroid Hormone  895  10-65 pg/ml Hemoglobin  8.6  14-17 gm/dl Hematocrit  27.4  40-54 % Mean cell volume  88  85-95 FL Renal ultrasound- Right kidney 9 x 6.0 cm, Left kidney 9.2 x 5.8 cm Both kidneys illustrate hyperechogenicity and no hydronephrosis. 24-hour urine protein and creatinine – volume 850 ml, protein 600 mg/dl and creatinine 180 mg/dl Case Questions 1.  “presents with a complaint of pruritis, lethargy, lower extremity edema, nausea and emesis.” what does the symptoms suggest to you? 2. What are the fundus changes in a hypertensive?  3. What are the fundus changes of a diabetic?  4. What does S4 signify? What cardiac findings will you expect to find in a hypertensive? 5. What are the possibilities for his 2+ lower extremity edema?   6. What is the significance of the finding ” superficial excoriations of his skin from scratching.”?  7. Why was a renal ultrasound ordered?  What information can you gather from renal ultrasound studies?  8 .How does the results of the renal ultrasound influence your thinking on the diagnosis? What is the normal size of the kidney?  Is his kidney size normal? What does small or large kidney signify?   9.  What is the significance of the report “Both kidneys illustrate hyperechogenicity”  How does evaluation of echogencity help in the diagnosis? 10. What evidence in renal ultrasound, will suggest obstruction?  11. Is the cause of this patient�s renal failure acute or chronic? How did you arrive at that conclusion? 12. What is the calculated GFR? 13. What would be the calculated GFR in this case, if the patient was female? 14. What is the 24 hour urine protein excretion in this patient?  15. Is this 24 hour urine collection adequate? How did you arrive at that conclusion?  16. How is a 24 hour urine to be collected and when is it appropriate to order this test?   17. What is the measured GFR in this patient?   18. Why is the parathyroid hormone elevated?   19. What is the most likely cause of this patient�s anemia?  20. Should this patient be started on dialysis? What are the indications for dialysis?  21.What is the most likely diagnosis for his renal disease? How did you arrive at that conclusion?  22. What are the most likely histological findings on renal biopsy in this patient?  23. Could his renal failure be due to hypertension? What evidence you will need to implicate hypertension as the cause for his renal failure? 24. If you were to place this patient on a 2 gram sodium diet how many milliequivalents of sodium would this diet contain?  25. How many grams of sodium chloride would this be? Foundations of Nursing Assignments Infection Case Study Read the two case study details before and answer the questions that follow them. A healthcare student is assigned to a client who is on isolation precautions and needs assistance with hygiene and elimination. The client is 47 years old, diagnosed with clostridium difficile (C.Diff.) and wears an adult brief due to incontinence of stool. The client has requested assistance with bathing and changing their brief. What infection prevention and control practices should be incorporated to decrease the risk of spreading infection when providing care? What infection prevention education should be shared with the client and their family? The client is on isolation precautions, how may this impact the client? A 10 year old client has been admitted to a clinic with the influenza virus and has a fever, persistent productive cough, and a runny nose. The client is lethargic and has not ate since yesterday morning due to nausea. Which client symptoms increase the risk of spreading the infection to the healthcare staff and other clients at the clinic? What personal protective equipment (PPE) would you wear while providing care? What teaching strategies should be implemented with the client and family to help control and eliminate the infection and potential reservoirs where pathogens can live? Concepts of Professional Nursing Communication Case Study Answer the following case study questions about therapeutic communication in thorough sentences. You may submit your response in Word document or type into the provided field.  1. A nurse is talking with a client who is recovering from a panic attack and tells the nurse that he feels embarrassed by the situation. What response would you give the client? Keep in mind that encouraging comparison can help to bring out information about recurring experiences and can help the client clarify similarities and differences between the situations. 2. A nurse is caring for a client who tells the nurse that he is feeling very stressed and overwhelmed. What response would give the client? Keep in mind that the nurse should encourage the client to share information about his perceptions of stress by asking open-ended questions. 3. A nurse is talking with a client who is crying and appears anxious. The client states, “My teenage daughter and I are always yelling and arguing.” What response would you give the client? Keep in mind that encouraging the formulation of a plan of action can assist the client to identify some alternative actions for possible resolution of the situation.

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