BIO 307 Case Study Exam Case Study 1:
J.A. is an 83-year-old male who presents to his PCP complaining of a “strange rhythmic, throbbing sensation in the middle of his abdomen.” He has sensed this feeling for the past three days. For the past several weeks he has also experienced deep pain in his lower back that “feels like it is boring into my spine.” He describes the pain as persistent but may be relieved by changing position. “I think that I hurt my back lifting some firewood,” he explains. The patient has never smoked. BIO 307 Case Study Exam.
Past Medical History:
Triple coronary artery bypass surgery at age 73
History of cluster headache
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History of psoriasis
Recent history of hypercholesterolemia
Medications:
Celecoxib 200 mg po QD
Aspirin 81 mg po QD
Clopidogrel 75 mg po QD
Simvastatin 20 mg po HS
Multivitamin tablet QD
Physical Exam and Lab Results:
Auscultation of the abdomen revealed a significant bruit over the aorta. Palpation of the abdomen revealed an abnormally wide pulsation of the abdominal aorta with some tenderness. When questioned, the patient denied nausea, vomiting, urinary problems, loss of appetite, heart failure, drug allergies, and a history of family members who had been diagnosed with an aortic aneurysm. BIO 307 Case Study Exam.
The patient’s vital signs were as follows: BP 150/95; HR 83; RR 14; T 98.8°F; WT 158 lbs; HT 5’9”
Patient Case Question 1. Based on the patient’s vital signs, which type of medication is indicated?
A CBC was ordered and the results of the CBC are as follows:
Complete Blood Count Hb 13.9 g/dL. WBC Differential Hct 43%. Neutrophils 59%. WBC 5,100/mm3. Lymphocytes 32%. RBC 6.0 million/mm3. Monocytes/Macrophages 5%. Plt 315,000/mm3. Eosinophils 3%. ESR 6 mm/hr. Basophils 1%.
Patient Case Question 2. What important information can be gleaned from the patient’s CBC?
Laboratory Blood Test Results: Na+ 145 meq/L. Glucose fasting 112 mg/dL. AST 15 IU/L K+ 4.9 meq/L Uric acid 2.9 mg/dL ALT 37 IU/L Cl- 104 meq/L BUN 9 mg/dL Total bilirubin 1.0 mg/dL Ca+2 8.7 mg/dL Cr 0.7 mg/dL Cholesterol 202 mg/dL Mg+2 2.3 mg/dL Alk Phos 79 IU/L HDL 50 mg/dL PO4-3 3.0 mg/dL PSA 11.6 ng/mL LDL 103 mg/dL HCO3- 27 meq/L Alb 3.5 g/dL Trig 119 mg/dL
Patient Case Question 3. Which single abnormal laboratory value has to be of most concern?
An abdominal x-ray was performed, a localized dilation of the abdominal aorta was visualized, and calcium deposits were seen within the aortic aneurysm. BIO 307 Case Study Exam.
Patient Case Question 4. What has caused the calcium deposits in the aorta?
Patient Case Question 5. What type of imaging test is now most appropriate in this patient?
An abdominal aortic aneurysm of 6.5 cm in diameter was located at the level of the renal arteries and extended downward into the iliac arteries.
Patient Case Question 6. Would a ”wait-and-see” approach be appropriate or should surgery be advised for this patient?
Case Study 2:
HPI:
Mrs. R.B. is a 52-year-old woman with a 40-year history of type 1 diabetes mellitus. Although she has been dependent on insulin since age 12, she has enjoyed relatively good health. She has been very careful about her diet, exercises daily, sees her primary care provider regularly for checkups, and is very conscientious about monitoring her blood glucose levels and self-administration of insulin. She is slightly overweight and was diagnosed with hypertension four years ago. Her high blood pressure has been well controlled with a thiazide diuretic. She does not smoke and rarely drinks alcoholic beverages. Mrs. B. was planning to shop at the local supermarket on Saturday, but her son telephoned her at the last minute and apologized that he had to work and could not drive her. Since she had only a few necessary items to pick up, she decided to walk the five blocks to the store. Rather than wear her usual walking shoes, she wore a pair of more fashionable shoes. Upon her return home, Mrs. B. removed her shoes and noticed a small blister on the ball of her right foot BIO 307 Case Study Exam. She felt no discomfort from the blister. However, two days later, she was alarmed when she found that the blister had developed into a large, open wound that was blue-black in color. For the next two days, she carefully cleansed the wound and covered it with sterile gauze each time. The wound did not heal and, in fact, became progressively worse and painful. Her son urged her to seek medical attention, and five days after the initial injury she made an appointment with her primary care provider.
Patient Case Question 1. Identify this patient’s two
most
critical risk factors for peripheral arterial disease.
Mrs. B.’s foot wound is approximately 1 inch in diameter and contains a significant amount of necrotic tissue and exudate. Furthermore, there is a lack of pink granulation tissue—an indication that the wound is not healing. The patient has a history of bilateral intermittent claudication, but denies pain at rest and recent numbness, tingling, burning sensations, and pain in her buttocks, thighs, calves, or feet. Examination of the peripheral pulses revealed normal bilateral femoral and popliteal pulses. However, the right dorsalis pedis artery and right posterior tibial artery pulses were not palpable. The patient has no history of coronary artery disease or cerebrovascular disease.
Patient Case Question 2. What level of peripheral arterial disease is suggested by her pulse examination: iliac disease, femoral disease, superficial femoral artery disease, or tibial disease?
Patient Case Question 3. Briefly describe the locations of the dorsalis pedis artery and posterior tibial artery pulses.
Physical Examination:
A pallor test revealed level 3 pallor in the right lower leg and foot and level 1 pallor in the left lower extremity. Ankle-brachial tests were conducted.
Left brachial systolic pressure: 130 mm Left ankle systolic pressure: 110 mm Right brachial systolic pressure: 125 mm Right ankle systolic pressure: 75 mm
Patient Case Question 4. What conclusions can be drawn from the pallor and anklebrachial test results?
A careful physical examination of the patient’s feet and legs revealed that both feet were cool to the touch and the toes on her right foot were slightly cyanotic. However, there was no mottling of the skin and sensory, reflex, and motor functions of both legs were intact.
Vital Signs BP 130/90 sitting RR 18 Ht 62 P 95 and regular T 99.8°F Wt 145 lb
Patient Case Question 5. Why is it likely that the patient’s body temperature is elevated?
Laboratory Blood Test Results:
Hb 15.1 g/dL Monocytes 3% ESR 20 mm/hr Hct 41% Eosinophils 1% BUN 10 mg/dL Plt 318,000/mm3 Na 139 meq/L Creatinine 0.7 mg/dL WBC 11,900/mm3 K 4.3 meq/L T cholesterol 291 mg/dL Neutrophils 80% Cl 108 meq/L LDL 162 mg/dL Lymphocytes 16% Glu, fasting 210 mg/dL HDL 26 mg/dL
Patient Case Question 6. What major conclusions can be drawn from the patient’s blood work?
Patient Case Question 7. Does Mrs. B. have any signs of renal insufficiency, a common chronic complication of diabetes mellitus?
Case Study 3:
Mr. R.I. is a 69-year-old man, who has been referred to the Pulmonary Disease Clinic by his nurse practitioner. He presents with the following chief complaints: “difficulty catching my breath and it is getting worse; a persistent, dry, and hacking cough; and a tight feeling in my chest.” He is a retired construction contractor of 45 years, who primarily installed insulation materials in high-rise apartment and office buildings. He has been retired for four years and first began experiencing respiratory symptoms approximately six months ago. He has attributed those symptoms to “being a long-time smoker and it is finally catching up with me.”
Past Medical and Surgical History:
Appendectomy at age 13
Osteoarthritis in left knee (high school football injury) x 30 years
Status post-cholecystectomy, 16 years ago
Benign prostatic hyperplasia, transurethral resection 7 years ago
Hypertension x 7 years
Hyperlipidemia x 4 years
Gastroesophageal reflux disease x 4 years
Family History:
Paternal history positive for coronary artery disease
Father died at age 63 from “heart problems”
Maternal history positive for cerebrovascular disease
Mother died at age 73 “following several severe strokes”
Brother died in a boating accident at age 17
Social History:
Previously divorced twice, but currently happily married for 23 years with 3 grown children (ages 40, 45, and 49)
Enjoys renovating old houses as a hobby and watching NASCAR racing and football on television
Smokes 1 pack per day x 45 years
Rarely exercises
Drinks “an occasional beer with friends on weekends” but has a history of heavy alcohol use
Volunteers in the community at the food pantry and for Meals on Wheels
No history of intravenous drug use
Review of Systems:
Denies rash, nausea, vomiting, diarrhea, and constipation
Denies headache, chest pain, bleeding episodes, dizziness, and tinnitus
Denies loss of appetite and weight loss
Reports minor visual changes recently corrected with stronger prescription bifocal glasses
Complains of generalized joint pain, but especially left knee pain
Has never been diagnosed with chronic obstructive pulmonary disease or any other pulmonary disorder Denies paresthesias and muscle weakness
Negative for urinary frequency, dysuria, nocturia, hematuria, and erectile dysfunction
Medications
Acetaminophen 325 mg 2 tabs po Q 6H PRN
Ramipril 5 mg po BID
Atenolol 25 mg po QD
Pravastatin 20 mg po QD
Famotidine 20 mg po Q HS
Allergies:
Terazosin (“It makes me dizzy and I fell twice when I was taking it.”)
Penicillin (rash)
Vital Signs
Blood pressure (sitting, both arms) average 131/75 mm Hg
Pulse 69 beats per minute
Respiratory rate 29 breaths per minute and slightly labored
Temperature 98.6°F
Pulse oximetry 95% on room air
Height 5’9”
Weight 179 lb
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Skin
Pallor noted
No lesions or rashes
Warm and dry with satisfactory turgor
Nail beds are pale
Head, Eyes, Ears, Nose, and Throat
Extra-ocular muscles intact
Pupils equal at 3 mm with normal response to light
Funduscopy within normal limits (no hemorrhages or exudates)
No strabismus, nystagmus, or conjunctivitis
Sclera anicteric
Tympanic membranes within normal limits bilaterally
No sinus tenderness
Oral pharyngeal mucosa clear
Mucous membranes moist but pale
Patient Case Question 1. What is the significance of an absence of hemorrhages and exudates on funduscopic examination?
Neck and Lymph Nodes
Neck supple
Negative for jugular venous distension and carotid bruits
No lymphadenopathy or thyromegaly
Laboratory Test Results:
Na 142 meq/L Cr 0.9 mg/dL WBC 9,200/mm3 K 4.9 meq/L Glu, fasting 97 mg/dL Plt 430,000/mm3 Cl 105 meq/L Ca 9.1 mg/dL pH 7.35 HCO3 22 meq/L Hb 15.9 g/dL PaO2 83 mm Hg BUN 12 mg/dL Hct 41% PaCO2 47 mm Hg
Patient Case Question 2. Is the patient hypoxemic or hypercapnic?
Patient Case Question 3. Is the patient acidotic or alkalotic?
Chest X-Ray
A posteroanterior radiograph showed coarse linear opacities at the base of each lung (more prominent on the left) that obscured the cardiac borders and diaphragm (shaggy heart border sign).
Patient Case Question 4. These findings are consistent with what disease?
High-Resolution CT Scan
Thickened septal lines and small, rounded, subpleural, intralobular opacities in the lower lung zone bilaterally suggest fibrosis. Ground-glass appearance involving air spaces in the upper lung zone bilaterally suggests alveolitis. Small, calcified diaphragmatic pleural plaques and mild “honeycomb” changes with cystic spaces less than 1 cm were seen bilaterally and are consistent with asbestosis.
Patient Case Question 5. What is the drug of choice for treating patients at this intermediate stage of asbestosis?
Case Study 4:
J.T. is a 61 yo man with COPD who presents to the emergency room with a three-day history of progressive dyspnea, cough, and increased production of clear sputum. He usually coughs up only a scant amount of clear sputum daily, and coughing is generally worse after rising in the morning. The patient denies fever, chills, night sweats, weakness, muscle aches, joint aches, and blood in the sputum. He treated himself with albuterol MDI, but respiratory distress increased despite multiple inhalations. Upon arrival at the emergency room, there were few breath sounds heard with auscultation, and the patient was so short of breath that he had difficulty climbing up onto the examiner’s table and completing a sentence without a long pause. He was placed on 4 L oxygen via nasal cannulae and given nebulized ipratropium and albuterol treatments BIO 307 Case Study Exam.
Past Medical History
History of mental illness as a young adult; one suicide attempt at age 20
HTN x 10 years
COPD diagnosed 6 years ago
Left lateral malleolus and first metatarsal fracture repair 17 months ago
Occasional episodes of acute bronchitis treated as outpatient with antibiotics
Mild CVA 4 months ago, appears to have no residual neurologic deficits
(–) history of TB, asbestos exposure, occupational exposure, heart disease, or asthma
Family History
Father died from lung cancer
Mother is alive, age 80, also has COPD and is being treated with oxygen
One sister, developed heart disease in her 50s
One daughter and three grandchildren, alive and well
Social History
Patient is a recently retired beef products worker
Married once and divorced at age 35, has not remarried
Lives with elderly mother
2 pack/day Camelsmoker for 37 years; has cut back to 5 cigarettes/day since he was diagnosed with COPD and is now willing to consider complete smoking cessation
History of excessive alcohol use; has become a social drinker in last 15 years
Review of Systems
Denies recent weight loss but has lost 25 pounds during past 7 years
Denies progressive fatigue, loss of libido, morning headaches, and sleeping problems BIO 307 Case Study Exam.
Vital Signs:
BP 165/95 RR 32 and labored HT 5’10” P 110 and regular. T 97.9°F WT 120 lb
Chest and Lungs
Use of accessory muscles at rest
“Barrel chest” appearance
Poor diaphragmatic excursion bilaterally
Percussion hyper-resonant
Poor breath sounds throughout
Prolonged expiration with occasional mild, expiratory wheeze
(–) crackles and rhonchi
(–) axillary and supraclavicular lymphadenopathy
Abdomen
(+) hepatosplenomegaly, fluid wave, tenderness, and distension
(–) masses, bruits, and superficial abdominal veins
Normal Bowel Sounds
Musculoskeletal and Extremities
Cyanotic nail beds (-) clubbing
1+ bilateral ankle edema to mid-calf
2+ dorsalis pedis and posterior tibial pulses bilaterally
(-) spine and CVA tenderness
Denies muscle aches, joint pain, and bone pain
Normal range of motion throughout BIO 307 Case Study Exam
Pulmonary Function Tests
FEV1 1.67 L (45% of expected)
FVC 4.10 L (85% of expected)
FEV1/FVC 0.41 (expected = 0.77)
Chest X-Rays
Hyperinflation with flattened diaphragm
Large anteroposterior diameter
Diffuse scarring and bullae in all lung fields but especially prominent in lower lobes bilaterally
No effusions or infiltrates
Large pulmonary vasculature
Patient Case Question 1. Identify all of this patient’s risk factors for chronic obstructive pulmonary disease and note which of them is the single most significant risk factor.
Patient Case Question 2. Identify all of the clinical manifestations in this patient that are consistent with chronic bronchitis.
Patient Case Question 3. Identify all of the clinical manifestations in this patient that are consistent with emphysema.
Patient Case Question 4. To which stage of development has this patient’s COPD progressed? BIO 307 Case Study Exam
Case Studies Assignment
Student’s Name
Institution of Affiliation
Course Name
Date
Case Study 1
The patient’s vital signs clearly indicate that the patient has high blood pressure, which is a risk factor for an abdominal aortic aneurysm. Therefore, an anti-hypertensive medication, preferably a beta blocker should immediately be indicated to reduce blood pressure and the stress exerted on the walls of the abdominal aorta (Davis, Rateri & Daugherty, 2015). Besides, this patient has no contraindications to therapy with beta blockers such as an allergy, severe heart failure, COPD or bradycardia.
Although a CBC is necessary in patients with an abdominal aortic aneurysm to assess for the likelihood of an infection, the need for transfusion and if the aneurysm is leaking and the patient is internally losing blood, this patient’s blood values were all within the normal range, an indication that there was no current risk of internal bleeding (Davis, Rateri & Daugherty, 2015) BIO 307 Case Study Exam.
Based on the laboratory test results, it is undeniable that all the other values are within the normal range apart from the serum Prostate Specific Antigen which is slightly elevated to 11.6ng/ML and should be of most concern. PSA is a test used to detect for prostate cancer in patients over 50 years of age. However, it does not necessarily indicate that a patient could be having prostate cancer but could be a warning sign on the need for additional tests since some benign conditions can raise the PSA levels
Calcification of the aorta in this patient occurred as a result of atherosclerosis where the arteries become clogged with fatty tissues, high levels of cholesterol and high blood pressure (Davis, Rateri & Daugherty, 2015).
A contrasted enhanced CT scan is the most recommended imaging test for this patient as it will benefit the clinician to detect the exact size of the aneurysm and will help in defining its relationship with the surrounding renal arteries.
This patient’s aneurysm was noted to be 6.5 cm in diameter and he also had hypertension. This can only suggest that a wait and see approach will only increase the patient’s risk for rupture.
Case Study 2
RB’s two potential risk factors for peripheral arterial disease are: hypertension and diabetes (Kullo & Rooke, 2016).
The examination of the pulse highly suggests that the existence of peripheral arterial disease is at the tibial artery level BIO 307 Case Study Exam.
The location of the dorsalis pedis artery pulse is between the 1
st
and 2
nd
metatarsal bones just at the tip of the foot. The posterior tibial artery pulse is found at the Pimenta point of the lower limbs. More specifically, it is located close to the insertion point of the Achilles tendon and the medial malleolus.
Based on the physical examination, it was notable that the client had level 3 pallor in the right lower limb and this is suggestive that it had a severe occlusive disease. In the left extremity, level 1 pallor suggests some decrease in the flow of blood but not to an extent that is similar to the one observed in the right leg (Kullo & Rooke, 2016). A left ankle-brachial index (ABI) of 0.85 indicates severe peripheral arterial disease of the left lower limb as well and a right ABI of 0.60 is undeniably an indication of severe obstruction.
The most probable reason that explains the rise in the patient’s body temperature is infection and inflammation of the wound on the patient’s right foot. Fever therefore occurs as a result of the release of endogenous pyrogen through an increment in the WBC count. High pyrogen levels therefore act on the hypothalamus and trigger a series of activities in the sympathetic nervous system which lead to vasoconstriction of capillaries in the skin which also reduces the amount of heat loss
Conclusions from the patient’s blood work. BIO 307 Case Study Exam.
Based on the patient’s blood work, the following conclusions can be drawn:
A high ESR rate and WBC count are suggestive of inflammation and an infection (Kullo & Rooke, 2016).
Since in the differentials of the white blood cells the percentage of neutrophils is highly elevated, it is likely that the client has a bacterial infection
High stress levels for the patient as a result of the infection have led to poor control of blood glucose. This can be explained by the fact that when stressed, the body releases catecholamine and cortisol. These hormones trigger hepatic glycogenolysis and gluconeogenesis which influence hyperglycemia.
Based on the lipid profile of the patient, it can easily be concluded that it is poor. The low-density lipoproteins are elevated, total cholesterol is significantly high and the levels of high density lipoproteins which form good cholesterol are low. It should be noted that hyperlipidemia is a potential risk factor for peripheral arterial disease which the patient has (Kullo & Rooke, 2016). This means that since the lipid profile of the patient is undeniably poor, he urgently needs lipid-lowering drugs, most preferably statins.
Despite the fact that renal failure and renal insufficiency are some of the most common complications of diabetes mellitus, the serum creatinine levels and Blood Urea Nitrogen(BUN) show that the patient’s kidney functioning is within the normal limits.
Case Study 3
Apart from revealing that the patient’s fundus is normal, the absence of exudates and hemorrhages exhibits that the patient was not at risk of mesothelioma, a type of cancer that arises from thin membranes which surround internal organs including the eye in even low levels of exposure BIO 307 Case Study Exam.
The patient is hypoxemic as primarily characterized by a slow heart rate and a fast respiratory rate as a mechanism to meet the body’s oxygen demand. The pale mail beds and a pulse oximetry of 95% also signify hypoxemia (Narewskiet al., 2018).
The patient is acidotic, indicating that the lungs cannot remove adequate CO
2
that is produced by the body. The buildup of CO
2
reduces the blood’s ph., making it too acidic. It is for this reason that the patient reported a lot of difficulty catching his breath.
These findings were consistent with asbestosis. Asbestosis is a chronic respiratory condition which results from prolonged exposures to asbestos fibers (Narewskiet al., 2018). Based on the fact that the client initially worked as a construction contractor for 45 years and even in his retirement he enjoys renovating old houses, the likelihood that he is suffering from asbestosis is significantly high.
There is no drug indicated in this patient’s stage. However, it will be important to advice and educate the patient on the significance of not smoking and probably refer him to a smoking cessation clinic. Besides, he should be ceased from further exposure since it will only increase the progression rate. Oxygen therapy should also be included to relieve the shortness of breath experienced by the patient and to correct the low levels of blood oxygen (Narewskiet al., 2018).
Case Study 4
The COPD risk factors that this patient has are as follows: He smokes 2 packs in a single day, he has a positive history of asthma, a positive family history of lung cancer, he inhales secondhand smoke and has an advanced age. Among them all, the most significant risk factor is a social history of daily smoking 2 packs Camel cigars (Rennard & Drummond, 2015). The effects that come with smoking include: pursed lip breathing, nail beds which are cyanotic, a barrel chest and generally a weak appearance. BIO 307 Case Study Exam.
Significant signs and symptoms of chronic bronchitis include: a mild-moderate headache, body aches and symptoms of a col. However, he declined having night sweats, chills, fever, and general body weakness (Rennard & Drummond, 2015). It should however be noted that this client still reveals some symptoms of chronic bronchitis such as daily production of clear sputum, chest discomfort, SOD and a cough.
Emphysema is a respiratory condition whose primary symptom is shortness of breath. Among those affected, the lung air sacs are gradually damaged and as time progresses, alveoli inner walls do weaken and rupture resulting to the formation of air spaces that are much larger as compared to the required small airspaces. As a result, the lungs surface area decreases and so does the amount of oxygen supplied to the body through blood (Rennard & Drummond, 2015). This patient reported that he had a lot of difficulty ascending the stairs since he had difficulty in breathing. Besides, his nail finger beds were cyanotic.
Based on the FEV1 test performed on the patient, the client’s result is 45%. Therefore, he fits under the GOLD 2 category with moderate COPD. BIO 307 Case Study Exam.
References
Davis, F. M., Rateri, D. L., & Daugherty, A. (2015). Abdominal aortic aneurysm: novel mechanisms and therapies.
Current opinion in cardiology
,
30
(6), 566.
Kullo, I. J., & Rooke, T. W. (2016). Peripheral artery disease.
New England Journal of Medicine
,
374
(9), 861-871.
Narewski, E. R., Simpson, S., Ramzy, J., Kraft, J., & Ngo, R. (2018). Asbestosis, pneumoconiosis, and other occupational lung diseases. In
Essentials of Clinical Pulmonology
(pp. 540-550). CRC Press.
Rennard, S. I., & Drummond, M. B. (2015). Early chronic obstructive pulmonary disease: definition, assessment, and prevention.
The Lancet
,
385
(9979), 1778-1788. BIO 307 Case Study Exam