Nrsg Case Scenario Question & Answer Guide (With Explanation)

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Original Question

NRSG 671 W7 Case Scenario Three Chief Complaint “Leg pain for a few months.” History of Present Illness A 78-year-old man, well established in this primary care clinic, presents complaining of leg pain that has been bothering him for the past few months. He states that the severity is 4/10. He complains of crampy calf pain in both legs, which occurs about 15 minutes into his twice-daily walks with his dog. The pain only goes away when he stops walking and sits for about 5 minutes. Once he starts walking again, the pain returns just a few minutes later. He also states that his legs feel weak. He reports pain relief upon elevating his legs while relaxing in his recliner but reports he sometimes cannot sleep at night as his legs start cramping when he lies down. He feels he cannot hold them still because the pain at times becomes an intense 6/10 to 7/10 severity until he falls asleep. He denies taking any medications for this pain but states standing in one place for an extended period, such as when fishing, also makes the pain return. Review of Systems The ROS is positive for leg cramps and weakness, varicose veins, and arthritis in hands and feet. The ROS is negative for fainting, blackouts, seizures, weakness, paralysis, tingling, tremors, or erectile dysfunction. He denies chest pain, palpitations, dyspnea at rest or upon exertion, orthopnea, paroxysmal nocturnal dyspnea, edema, and any recent trauma to his lower extremities. Relevant Medical and Social History The patient has hypercholesterolemia, hypertension, and bilateral cataracts with lens implants. The patient is a retired engineer, happily married to his wife of 54 years. He is a former tobacco abuser, 2 packs per day for 30 years; he quit at age 48. He enjoys two martinis with dinner each evening and denies recreational or illicit drug use ever. His family history is significant for lung cancer, acute MI, hyperlipidemia, and hypertension. He attends church weekly with his wife. Allergies No known drug allergies; no known food allergies Medications • Atorvastatin 40 mg PO QHS • Amlodipine 5 mg PO QD Physical Examination Vitals: T 36.9°C (98.4°F), P 78, R 14, BP 146/88, HT 178 cm (70 in.), WT 82.6 kg (182 lbs.), BMI 26.1 General: Male of stated age sitting comfortably on the examination table, in no acute distress. Makes good eye contact, converses with ease, makes jokes. A&O x 3 Skin, Hair, and Nails: Tight, thin, shiny, atrophied skin, slightly dusky red/ruborous color, overlying dorsum of mid-feet to include all toes, extending proximally and circumferentially to bilateral ankles and knees. Bald, slightly cool to the touch bilaterally and symmetrically. No lesions or masses. Thin, short brittle nails bilateral feet Head: Atraumatic, normocephalic Neck: Trachea midline, no masses or lymphadenopathy Lungs: Clear to auscultation bilaterally without wheezes or rales Heart: RRR; no murmurs, rubs, or gallops Peripheral Vascular: Carotid pulses 2+ bilaterally; no thrills or bruits. Distal upper extremity pulses 2+ and symmetric bilaterally, capillary refill <2 seconds. Distal lower extremity pulses: femoral and popliteal pulses 1+ symmetric bilaterally, posterior tibial pulses 1+ symmetric bilaterally. Dorsalis pedis pulses weak bilaterally with sluggish capillary refill. Spider vein varicosities throughout BLEs. With patient lying supine, great toes blanch while lower extremities are extended and held superiorly to approximately 60°. When lower extremities are returned to the supine position, the great toes return to their original dusky red color/rubor within 6 seconds Musculoskeletal: FROM BUEs. LROM bilateral feet and ankles, lower extremity muscle atrophy bilaterally, most notably bilateral calves distal to feet Neurologic: Cranial nerves II to XII grossly intact. Negative Romberg, antalgic gait with heel- to-toe walking, walking on heels, and walking on toes PRIMARY DX: Peripheral artery disease (PAD) 1. Summarize evidence-based management guidelines for chronic kidney disease (CKD). Express the impact of the social determinants of health including cultural, psychological, and spiritual factors on complex health conditions. Discuss some of the objective findings anticipated in patients with a diagnosis of nephrolithiasis and pyelonephritis. Discuss why pyelonephritis is such an emergent condition and how complicated pyelonephritis may be associated with chronic nephrolithiasis.

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