CASE STUDY 3: Focused Ear Exam 

Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked. He has complained to her about a mild earache for the past 2 days. His grandmother believes that he feels warm but did not verify this with a thermometer. James states that the pain was worse while he was falling asleep and that it was harder for him to hear. When you begin basic assessments, you notice that James has a prominent tan. When you ask him how he’s been spending his summer, James responds that he’s been spending a lot of time in the pool.

Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

Photo Credit: Getty Images/Blend Images

Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.

Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.

In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

To Prepare

• By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
• Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.

With regard to the case study you were assigned:

• Review this week’s Learning Resources and consider the insights they provide.
• Consider what history would be necessary to collect from the patient.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Assignment

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.

 

Rubric

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• List View

ExcellentGoodFairPoorUsing the Episodic/Focused SOAP Template:
· Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned.

·  Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.45 (45%) – 50 (50%)The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.39 (39%) – 44 (44%)The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.33 (33%) – 38 (38%)The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected.0 (0%) – 32 (32%)The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.·   List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.30 (30%) – 35 (35%)The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five conditions selected.24 (24%) – 29 (29%)The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.18 (18%) – 23 (23%)The response lists three to five possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.0 (0%) – 17 (17%)The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.5 (5%) – 5 (5%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.4 (4%) – 4 (4%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.3 (3%) – 3 (3%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.0 (0%) – 2 (2%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation5 (5%) – 5 (5%)Uses correct grammar, spelling, and punctuation with no errors.4 (4%) – 4 (4%)Contains a few (1 or 2) grammar, spelling, and punctuation errors.3 (3%) – 3 (3%)Contains several (3 or 4) grammar, spelling, and punctuation errors.0 (0%) – 2 (2%)Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.5 (5%) – 5 (5%)Uses correct APA format with no errors.4 (4%) – 4 (4%)Contains a few (1 or 2) APA format errors.3 (3%) – 3 (3%)Contains several (3 or 4) APA format errors.0 (0%) – 2 (2%)Contains many (≥ 5) APA format errors.Total Points: 100ReplyForward
ReplyForward

following the below posting instruction initial posting one page with two reference and incitation one reference text book and other scholarly not older than 5 years.

Required Resources
Read/review the following resources for this activity:

• Textbook: Chapter 1 tenth edition the Humanity through the arts. author Lee A Jacobs/David Martin
• Minimum of 1 scholarly source (in addition to the textbook)

Initial Post Instructions
For the initial post, address the following:

• What is the value of studying the humanities in the field of health professions?
• How might a topic such as art, literature, music, dance, etc. from other time periods enhance your career and personal life in the present?
• Select one aspect of the humanities that is meaningful to your personal life and one for career. Explain how is each meaningful.
• In addition, include a specific example of a work (a specific work of art, literature, theater, or music) that you feel is meaningful to your personal life and/or career. Explain the connection.

Purpose

Problem-based learning is a methodology designed to help students develop the reasoning process used in clinical practice through problem solving actual patient problems in the same manner as they occur in practice.  The purpose of this activity is to develop students’ clinical reasoning skills using a case-based learning exercise. Through participation in an online discussion forum, students identify learning issues in a self-directed manner which facilitates learning for the entire group.

Case Study & Discussion Questions

John is a 46-year-old male who presents for his yearly physical examination. He has no complaints. Previous medical history is notable for obesity and hyperlipidemia. He reports a very sedentary lifestyle. He sits at a desk for 8 to 10 hours per day and when he comes home he “just wants to relax in front of the television.” He doesn’t feel motivated enough to exercise on a regular basis, although he knows he should.

John is allergic to penicillin (hives). Medications include atorvastatin 10mg daily and a multivitamin. He occasionally takes acetaminophen for a headache.

Family history is significant for diabetes (mother, maternal grandmother, paternal grandfather) and hypertension (father and brother). He is a nonsmoker and reports drinking “a few beers on the weekend during football season”. His diet largely consists of fast food meals. He drinks sweet tea with every meal and an additional 3-4 cups of coffee per day. Previous labs and exam last year are unremarkable.

Vitals today: BP 130/70 mm Hg, pulse 82 and regular, temperature 98.7, respirations 18, height 6’1”, weight 235 pounds (up 3 lbs. since his visit 1 year ago). He completed fasting labs prior to this appointment as he was instructed which reveal the following:

Fasting plasma glucose=209 mg/dl, HgbA1C=9.1%, TSH=4.0mU/L and Free T4=1.1 ng/dl. Fasting lipid panel includes the following: total cholesterol=190 mg/dL, HDL=35 mg/dL, LDL=120 mg/dL and triglycerides=260 mg/dL.

Physical exam is remarkable for obesity but is otherwise normal.

· What are your treatment goals for John?

· What is your pharmacologic plan and rationale? (cite with appropriate clinical practice guidelines or scholarly, peer-reviewed journals)

· What is the mechanism of action for each drug?

· Please give five medication teaching points for each drug prescribed.

· How would you change the plan if his initial HbgA1C was 14.0 mg/dL and his fasting blood glucose was 350mg/dL along with a urine dipstick that revealed 3+ glucose and + ketones? Provide a detailed alternative plan with the rationale.

Discussion Guiding Principles

The ideas and beliefs underpinning the discussions guide students through engaging dialogues as they achieve the desired learning outcomes/competencies associated with their course in a manner that empowers them to organize, integrate, apply and critically appraise their knowledge to their selected field of practice. The use of discussions provides students with opportunities to contribute level-appropriate knowledge and experience to the topic in a safe, caring, and fluid environment that models professional and social interaction. The ebb and flow of a discussion is based upon the composition of student and faculty interaction in the quest for relevant scholarship. Participation in the discussion generates opportunities for students to actively engage in the written ideas of others by carefully reading, researching, reflecting, and responding to the contributions of their peers and course faculty. Discussions foster the development of members into a community of learners as they share ideas and inquiries, consider perspectives that may be different from their own, and integrate knowledge from other disciplines.

Direct Quotes

Good writing calls for the limited use of direct quotes. Direct quotes in discussions are to be limited to one short quotation (not to exceed 15 words). The quote must add substantively to the discussion. Points will be deducted under the grammar, syntax, APA category.

 

DISCUSSION CONTENT
Category	Points	%	Description
Application of Course Knowledge	35	35%	1. Decisions are well supported with evidence based medicine (EBM) arguments that are in-line with the scenario; AND 2. Proper rationale and reasoning skills are demonstrated; AND 3. Information is taken from source(s) with appropriate interpretation/evaluation to develop a comprehensive analysis or synthesis of the topic at hand; AND 4. Applies concepts to personal experience in the professional setting and/or information has relevant application to real life; AND 5. All of the post makes direct reference to concepts discussed in the lesson; AND 6. Posts are on topic and answer all presented questions which demonstrates a solid understanding of the topic. (6 critical elements)
Support from Evidence-Based Practice (EBP)	35	35%	1. Discussion post is supported with appropriate, scholarly sources; uses valid, relevant, and reliable outside sources to contribute to the threaded discussion; AND 2. Sources are published within the last 5 years (unless it is the most current CPG); AND 3. Reference list is provided and in-text citations match; AND 4. Provides relevant evidence of scholarly inquiry clearly stating how the evidence informed or changed professional or academic decisions (4 critical elements)
Interactive Dialogue	15	15%	1. Student provides a substantive* response to at least one topic-related post of a peer; AND 2. Evidence from appropriate scholarly sources are included; AND 3. Reference list is provided and in-text citations match; AND 4. Student responds to all direct faculty questions OR if student was not asked a direct question student responds to either a 2nd peer post or a faculty question directed towards another student (*) A substantive post adds new content or insights to the discussion thread and information from student’s original post is not reused in peer or faculty response (4 critical elements)
			Total CONTENT Points= 85 pts
DISCUSSION FORMAT
Category	Points	%	Description
Grammar, Syntax, Spelling & Punctuation	15	15%	Discussion post has minimal grammar, syntax, spelling, punctuation, or APA format errors* (*) APA style references and in text citations are required; however, there are no deductions for errors in indentation or spacing of references. All elements of the reference otherwise must be included.
			Total FORMAT Points= 15 pts
			DISCUSSION TOTAL= 100 pts

 

 

Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeApplication of Course Knowledge Decisions are well supported with EBM arguments that are in-line with the scenario; AND  Proper rationale and reasoning skills are demonstrated; AND  Information is taken from source(s) with appropriate interpretation/evaluation to develop a comprehensive analysis or synthesis of the topic at hand; AND  Applies concepts to personal experience in the professional setting and/or information has relevant application to real life; AND  All of the post makes direct reference to concepts discussed in the lesson; AND  Posts are on topic and answer all presented questions which demonstrate a solid understanding of the topic.  (6 critical elements)	35.0 pts Excellent All 6 critical elements are present. 32.0 pts V. Good 5 elements are present. 29.0 pts Satisfactory 3-4 elements are present. 18.0 pts Needs Improvement 1-2 elements are present. 0.0 pts Unsatisfactory 0 elements are present.	35.0 pts
This criterion is linked to a Learning OutcomeSupport from Evidence-Based Practice (EBP) Discussion post is supported with appropriate, scholarly sources; AND   Sources are published within the last 5 years (unless it is the most current CPG); AND  Reference list is provided and in-text citations match; AND  Provides relevant evidence of scholarly inquiry clearly stating how the evidence informed or changed professional or academic decisions  (4 critical elements)	35.0 pts Excellent All 4 critical elements are present. 32.0 pts V. Good 3 critical elements are present. 29.0 pts Satisfactory 2 critical elements are present. 18.0 pts Needs Improvement 1 critical element is present. 0.0 pts Unsatisfactory 0 critical elements are present. *Students should note that factitious sources, sources that are clearly not read by the student and used, or sources that have incorrect dates will result in an automatic ZERO (0) for this section for the week.	35.0 pts
This criterion is linked to a Learning OutcomeInteractive Dialogue Student provides a substantive* response to at least one topic-related post of a peer; AND  Evidence from appropriate scholarly sources are included; AND  Reference list is provided and in-text citations match; AND  Student responds to all direct faculty questions OR if student was not asked a direct question student responds to either a 2nd peer post or a faculty question directed towards another student  (*) A substantive post adds new content or insights to the discussion thread and information from student’s original post is not reused in peer or faculty response  (4 critical elements)	15.0 pts Excellent All 4 critical elements are present. 13.0 pts V. Good 3 critical elements are present. 12.0 pts Satisfactory 2 critical elements are present. 7.0 pts Needs Improvement 1 critical element is present. 0.0 pts Unsatisfactory 0 critical elements are present.	15.0 pts
This criterion is linked to a Learning OutcomeGrammar, Syntax, APA format Discussion post has minimal grammar, syntax, spelling, punctuation, or APA format errors*  (*) APA style references and in text citations are required; however, there are no deductions for errors in indentation or spacing of references. All elements of the reference otherwise must be included	15.0 pts Excellent 0-1 errors in grammar, syntax, spelling, punctuation, or APA format* 13.0 pts V. Good 2-3 errors in grammar, syntax, spelling, punctuation, or APA format* 12.0 pts Satisfactory 4-5 errors in grammar, syntax, spelling, punctuation, or APA format* 7.0 pts Needs Improvement 6-9 errors in grammar, syntax, spelling, punctuation, or APA format* 0.0 pts Unsatisfactory 10 or more errors in grammar, syntax, spelling, punctuation, or APA format*	15.0 pts
This criterion is linked to a Learning OutcomeDiscussion late penalty deductions A 10% late penalty will be imposed for discussions posted after the deadline on Wednesday, regardless of the number of days late. NOTHING will be accepted after 11:59pm MT on Sunday (i.e. student will receive an automatic 0)	0.0 pts Manual Deductions 0.0 pts Manual Deductions	0.0 pts
This criterion is linked to a Learning OutcomeTotal Participation Responses A 10% penalty will be imposed for not entering the minimum number of interactive dialogue posts (3) OR not posting on the minimum required number of days (3). NOTHING will be accepted after 11:59pm MT on Sunday (i.e. student will receive an automatic 0)	0.0 pts Manual Deductions 0.0 pts Manual Deductions

QUESTION 1

1. A 67-year-old Caucasian woman was brought to the clinic by her son who stated that his mother had become slightly confused over the past several days. She had been stumbling at home and had fallen once but was able to ambulate with some difficulty. She had no other obvious problems and had been eating and drinking. The son became concerned when she forgot her son’s name, so he thought he better bring her to the clinic.
   PMH-Type II diabetes mellitus (DM) with peripheral neuropathy x 20 years. COPD. Depression after death of spouse several months ago
   Social/family hx – non contributary except for 30 pack/year history tobacco use.
   Meds: Metformin 500 mg po BID, ASA 81 mg po qam, escitalopram (Lexapro) 5 mg po q am started 2 months ago
   Labs-CBC WNL; Chem 7- Glucose-92 mg/dl, BUN 18 mg/dl, Creatinine 1.1 mg/dl, Na+120 mmol/L,
   K+4.2 mmol/L, CO237 m mol/L, Cl-97 mmol/L.
   The APRN refers the patient to the ED and called endocrinology for a consult for diagnosis and management of syndrome of inappropriate antidiuretic hormone (SIADH).

   Question:
   Define SIADH and identify any patient characteristics that may have contributed to the development of SIADH.

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1 points  

QUESTION 2

1. A 43-year-old female presents to the clinic with a chief complaint of fever, chills, nausea and vomiting and weakness. She has been unable to keep any food, liquids or medications down. The symptoms began 3 days ago and have not responded to ibuprofen, acetaminophen, or Nyquil when she tried to take them. The temperature has reached as high as 102˚F.

   Allergies: none known to drugs or food or environmental

   Medications-20 mg prednisone po qd, omeprazole 10 po qam

   PMH-significant for 20-year history of steroid dependent rheumatoid arthritis (RA). GERD. No other significant illnesses or surgeries.

   Social-denies alcohol, illicit drugs, vaping, tobacco use

   Physical exam

   Thin, ill appearing woman who is sitting in exam room chair as she said she was too weak to climb on the exam table. VS Temp 101.2˚F, BP 98/64, pulse 110, Resp 16, PaO2 96% on room air.

   ROS negative other than GI symptoms.

   Based on the patient’s clinical presentation, the APRN diagnoses the patient as having secondary hypocortisolism due to the lack of prednisone the patient was taking for her RA secondary to vomiting.

   Question:

   Explain why the patient exhibited these symptoms? 

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1 points  

QUESTION 3

1. A 64-year-old Caucasian female presents to the clinic with vague symptoms of non- specific abdominal pain, myalgias, constipation, polyuria, and says she feels “fuzzy headed” much of the time. She had about of kidney stones a few weeks ago and she fortunately was able to pass the small stones without requiring lithotripsy or other interventions. She was told by the urologist to follow up with her primary care provider after the kidney stones has resolved.
   The APRN examining the patient orders a Chem 7 which revealed a serum Ca++ of 13.1 mg/dl. The APN believes the patient has primary hyperparathyroidism and refers the patient to an endocrinologist who does a complete work up and concurs with the APRN’s diagnosis.
   Question:
   What is the role of parathyroid hormone in the development of primary hyperparathyroidism? 

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1 points  

QUESTION 4

1. A 64-year-old Caucasian female presents to the clinic with vague symptoms of non- specific abdominal pain, myalgias, constipation, polyuria, and says she feels “fuzzy headed” much of the time. She had a fracture of her right metatarsal without trauma and currently is wearing a walking boot. She also had a bout of kidney stones a few weeks ago and she fortunately was able to pass the small stones without requiring lithotripsy or other interventions. She was told by the urologist to follow up with her primary care provider after the kidney stones has resolved.

   The APRN examining the patient orders a Chem 12 which revealed a serum Ca++ of 13.1 mg/dl. The APRN believes the patient has primary hyperparathyroidism and refers the patient to an endocrinologist who does a complete work up and concurs with the APRN’s diagnosis.

   Question 1 of 2:

   Explain the processes involved in the formation of renal stones in patients with hyperparathyroidism. 

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0.5 points  

QUESTION 5

1. A 64-year-old Caucasian female presents to the clinic with vague symptoms of non- specific abdominal pain, myalgias, constipation, polyuria, and says she feels “fuzzy headed” much of the time. She had a fracture of her right metatarsal without trauma and currently is wearing a walking boot. She also had a bout of kidney stones a few weeks ago and she fortunately was able to pass the small stones without requiring lithotripsy or other interventions. She was told by the urologist to follow up with her primary care provider after the kidney stones has resolved.
   The APRN examining the patient orders a Chem 12 which revealed a serum Ca++ of 13.1 mg/dl. The APRN believes the patient has primary hyperparathyroidism and refers the patient to an endocrinologist who does a complete work up and concurs with the APRN’s diagnosis.
   Question 2 of 2:
   Explain how a patient with hyperparathyroidism is at risk for bone fractures.  

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0.5 points  

QUESTION 6

1. A 64-year-old Caucasian female who is 4 weeks status post total parathyroidectomy with forearm gland insertion presents to the general surgeon for her post-operative checkup. She states that her mouth feels numb and she feels “tingly all over. The surgeon suspects the patient has hypoparathyroidism secondary to the parathyroidectomy with delayed vascularization of the implanted gland. She orders a Chem 20 to determine what electrolyte abnormalities may be present. The labs reveal a serum Ca++ of 7.1 mg/dl (normal 8.5 mg/dl-10.5 mg/dl) and phosphorous level of 5.6 mg/dl (normal 2.4-4.1 mg/dl).

   Question:

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1 points  

QUESTION 7

1. A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms.

   PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child

   Allergies-none know

   Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process

   Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast food store after school and on weekends.

   Labs in office: random glucose 220 mg/dl.

   Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan.

   Question 1 of 6:

   The patient exhibited classic signs of Type 1 diabetes. Explain the pathophysiology of “polydipsia.”

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1 points  

QUESTION 8

1. A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms.

   PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child

   Allergies-none know

   Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process

   Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast food store after school and on weekends.

   Labs in office: random glucose 220 mg/dl.

   Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan.
   Question 2 of 6:

   The patient exhibited classic signs of Type 1 diabetes. Explain the pathophysiology of “polyuria.”

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1 points  

QUESTION 9

1. A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms.
   PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child
   Allergies-none know
   Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process
   Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast food store after school and on weekends.
   Labs in office: random glucose 220 mg/dl.
   Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan.
   Question 3 of 6:
   The patient exhibited classic signs of Type 1 diabetes. Explain the pathophysiology of “polyphagia.”

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1 points  

QUESTION 10

1. A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms.

   PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child

   Allergies-none know

   Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process

   Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast food store after school and on weekends.

   Labs in office: random glucose 220 mg/dl.

   Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan.
   Question 4 of 6:
   The patient exhibited classic signs of Type 1 diabetes. Explain the pathophysiology of “weight loss.”

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0.5 points  

QUESTION 11

1. A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms.
   PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child
   Allergies-none know
   Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process
   Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast food store after school and on weekends.
   Labs in office: random glucose 220 mg/dl.
   Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan.
   Question 5 of 6:
   The patient exhibited classic signs of Type 1 diabetes. Explain the pathophysiology of “fatigue.”

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0.5 points  

QUESTION 12

1. A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms.
   PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child
   Allergies-none know
   Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process
   Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast food store after school and on weekends.
   Labs in office: random glucose 220 mg/dl.
   Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan.
   Question 6 of 6:
   How do genetics and environmental factors contribute to the development of Type 1 diabetes?

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1 points  

QUESTION 13

1. A 17-year-old boy recently diagnosed with Type I diabetes is brought to the pediatrician’s office by his parents with a chief complaint of “having the flu”. His symptoms began 2 days ago, and he has vomited several times and has not eaten very much. He can’t remember if he took his prescribed insulin for several days because he felt so sick. Random glucose in the office reveals glucose 560 mg/dl and the pediatrician made arrangements for the patient to be admitted to the hospitalist service with an endocrinology consult.

   BP 124/80mmHg; HR 122bpm; Respirations 32 breaths/min; Temp 97.2˚F; PaO297% on RA

   Admission labs: Hgb 14.6 g/dl; Hct 58%

   CMP- Na+ 122mmol/L; K+ 5.3mmol/L; Glucose 560mg/dl; BUN 52mg/dl; Creatinine 4.9mg/dl;

   Cl- 95mmol/L; Ca++ 8.8mmol/L; AST (SGOT) 248U/L; ALT 198U/L; CK 34/35 IU/L; Cholesterol 198mg/dl;

   Phosphorus 6.8mg/dl; Acetone Moderate; LDH38U/L; Alkaline Phosphatase 132U/L.

   Arterial blood gas values were as follows: pH 7.09; Paco220mm Hg; Po2100mm Hg; Sao2 98% (room air)

   HCO3-7.5mmol/L; anion gap 19.4

   A diagnosis of diabetic ketoacidosis was made, and the patient was transferred to the Intensive Care Unit (ICU) for close monitoring.

   Question:

   The hormones involved in intermediary metabolism, exclusive of insulin, that can participate in the development of diabetic ketoacidosis (DKA) are epinephrine, glucagon, cortisol, growth hormone. Describe how they participate in the development of DKA.

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1 points  

QUESTION 14

1. A 67-year-old African American male presents to the clinic with a chief complaint that he has to “go to the bathroom all the time and I feel really weak.” He states that this has been going on for about 3 days but couldn’t come to the clinic sooner as he went to the Wound Care clinic for a dressing change to his right great toe that has been chronically infected, and he now has osteomyelitis. Patient with known Type II diabetes with poor control. His last HgA1C was 10.2 %. He says he can’t afford the insulin he was prescribed and only takes half of the oral agent he was prescribed. Random glucose in the office revealed glucose of 890 mg/dl. He was immediately referred to the ED by the APRN for evaluation of suspected hyperosmolar hyperglycemic non ketotic syndrome (HHNKS). Also called hyperglycemic hyperosmolar state (HHS).

   Question:

   Explain the underlying processes that lead to HHNKS or HHS.

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1 points  

QUESTION 15

1. A 32-year-old woman presented to the clinic complaining of weight gain, swelling in her legs and ankles and a puffy face. She also recently developed hypertension and diabetes type 2. She noted poor short-term memory, irritability, excess hair growth (women), red-ruddy face, extra fat around her neck, fatigue, poor concentration, and menstrual irregularity in addition to muscle weakness. Given her physical appearance and history, a tentative diagnosis of hypercortical function was made. Diagnostics included serum and urinary cortisol and serum adrenocorticotropic hormone (ACTH). MRI revealed a pituitary adenoma.

   Question:

   How would you differentiate Cushing’s disease from Cushing’s syndrome? 

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1 points  

QUESTION 16

1. A 47-year-old female is referred to the endocrinologist for evaluation of her chronically elevated blood pressure, hypokalemia, and hypervolemia. The patient’s hypertension has been refractory to the usual medications such as beta blockers, diuretics, and angiotensin-converting enzyme (ACE) inhibitors. After a full work up including serum and urinary electrolyte levels, aldosterone suppression test, plasma aldosterone to renin ratio, and MRI which revealed an autonomous adenoma, the endocrinologist diagnoses the patient with primary hyper-aldosteronism.

   Question:

   What is the pathogenesis of primary hyper-aldosteronism? 

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1 points  

QUESTION 17

1. A 47-year-old African American male presents to the clinic with chief complaints of polyuria, polydipsia, polyphagia, and weight loss. He also said that his vison occasionally blurs and that his feet sometimes feel numb.  He has increased hunger despite weight loss and admits to feeling unusually tired. He also complains of “swelling” and enlargement of his abdomen.

   Past Medical History (PMH) significant for HTN fairly well controlled with and ACE inhibitor; central obesity, and dyslipidemia treated with a statin, Review of systems negative except for chief complaint. Physical exam unremarkable except for decreased filament test both feet. Random glucose in office 290 mg/dl. The APRN diagnoses the patient with type II DM and prescribes oral medication to control the glucose level and also referred the patient to a dietician for dietary teaching.

   Question:

   What is the basic underlying pathophysiology of Type II DM? 

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1 points  

QUESTION 18

1. A 21-year-old male was involved in a motorcycle accident and sustained a closed head injury. He is waking up and interacting with his family and medical team. He complained of thirst that doesn’t seem to go away no matter how much water he drinks. The nurses note that he has had 3500 cc of pale-yellow urine in the last 24 hours. Urine was sent for osmolality which was reported as 122 mOsm/L. A diagnosis of probable neurogenic diabetes insipidus was made.

   Question:

   What causes diabetes insipidus (DI)? 

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0.5 points  

QUESTION 19

1. A 43-year-old female patient presents to the clinic with complaints of nervousness, racing heartbeat, anxiety, increased perspiration, heat intolerance, hyperactivity and palpitations. She states she had had the symptoms for several months but attributed the symptoms to beginning to care for her elderly mother who has Alzheimer’s Disease. She has lost 15 pounds in the last 3 months without dieting. Her past medical history is significant for rheumatoid arthritis that she has had for the last 10 years well controlled with methotrexate and prednisone. Physical exam is remarkable for periorbital edema, warm silky feeling skin, and palpable thyroid nodules in both lobes of the thyroid. Pending laboratory diagnostics, the APRN diagnoses the patient as having hyperthyroidism, also called Graves’ Disease.

   Question:

   Explain how the negative feedback loop controls thyroid levels.

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1 points  

QUESTION 20

1. A 43-year-old female patient with known Graves’ Disease presents to the clinic with complaints of nervousness, racing heartbeat, anxiety, increased perspiration, heat intolerance, hyperactivity and severe palpitations. She states she had been given a prescription for propylthiouracil, an antithyroid medication but she did not fill the prescription as she claims she lost it. She had been given the option of thyroidectomy which she declined. She also notes that she is having trouble with her vision and often has blurry eyes. She states that her eyes seem “to bug out of her face”. She has had recurrent outs of nausea and vomiting. She was recently hospitalized for pneumonia.  Physical exam is significant for obvious exophthalmos and pretibial myxedema. Vital signs are temp 101.2˚F, HR 138 and irregular, BP 160/60 mmHg. Respirations 24. Electrocardiogram revealed atrial fibrillation with rapid ventricular response. The APRN recognizes the patient is experiencing symptoms of thyrotoxic crisis, also called thyroid storm. The patient was immediately transported to a hospital for critical care management.

   Question:

   How did the patient develop thyroid storm? What were the patient factors that lead to the development of thyroid storm? 

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1 points  

QUESTION 21

1. A 44-year-old woman presents to the clinic with complaints of extreme fatigue, weight gain, decreased appetite, cold intolerance, dry skin, hair loss, and sleepiness. She also admits that she often bursts into tears without any reason and has been exceptionally forgetful. Her vision is occasionally blurry, and she admits to being depressed without any social or occupational triggers. Past medical history noncontributory. Physicalexam Temp 96.2˚F, pulse 62 and regular, BP 108/90, respirations. Dull facial expression with coarse facial features. Periorbital puffiness noted. Based on the clinical history and physical exam, and pending laboratory data, the ARNP diagnoses the patient with hypothyroidism.

   Question:

   What causes hypothyroidism? 

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0.5 points  

QUESTION 22

1. A 44-year-old woman is brought to the clinic by her husband who says his wife has had some mental status changes over the past few days. The patient had been previously diagnosed with hypothyroidism and had been placed on thyroid replacement therapy but had been lost to follow-up due to moving to another city for the husband’s work approximately 4 months ago. The patient states she lost the prescription bottle during the move and didn’t bother to have the prescription filled since she was feeling better. Physical exam revealed non-pitting, boggy edema around her eyes, hands and feet as well as the supraclavicular area. The APRN recognizes this patient had severe myxedema and referred the patient to the hospital for medical management.

   Question:

   What causes myxedema coma? 

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0.5 points  

QUESTION 23

1. A 53-year-old woman presents to the primary care clinic with complaints of severe headaches, palpitations, highblood pressure and diaphoresis. She relates that these symptoms come in clusters and when she has these “spells”, she also experiences, tremor, nausea, weakness, anxiety, and a sense of doom and dread, epigastric pain, and flank pain. She had one of these spells when she was at the pharmacy and the pharmacist took her blood pressure which was recorded as 200/118. The pharmacist recommended that she immediately be evaluated for these symptoms. Past medical history significant for a family history of neurofibromatosis type 1 (NF1). Based on the presenting symptoms and family history of NF1, the APRN suspects the patient has a pheochromocytoma. Laboratory data and computerized tomography of the abdomen confirms the diagnosis.
   Question 1 of 2:

   What is a pheochromocytoma and how does it cause the classic symptoms the patient presented with? 

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0.5 points  

QUESTION 24

1. A 53-year-old woman presents to the primary care clinic with complaints of severe headaches, palpitations, highblood pressure and diaphoresis. She relates that these symptoms come in clusters and when she has these “spells”, she also experiences, tremor, nausea, weakness, anxiety, and a sense of doom and dread, epigastric pain, and flank pain. She had one of these spells when she was at the pharmacy and the pharmacist took her blood pressure which was recorded as 200/118. The pharmacist recommended that she immediately be evaluated for these symptoms. Past medical history significant for a family history of neurofibromatosis type 1 (NF1). Based on the presenting symptoms and family history of NF1, the APRN suspects the patient has a pheochromocytoma. Laboratory data and computerized tomography of the abdomen confirms the diagnosis.
   Question 2 of 2:
   What are the treatment goals for managing pheochromocytoma? 

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