Question

A 62-year-old Caucasian female presents for a return visit for monitoring of arthritic pain in her knees. She has informed the medical assistant taking her vital signs that she wants to make sure that the nurse practitioner also checks out her arms and chest because she has noticed blood-like spots under the skin on her body that she has not had before. She notes having bruising in her past not related to injury that she attributes to taking quinine for leg cramps; when she discontinued the quinine, the bruising went away. She states that her knee pain has gotten better now that she is taking her prescribed naproxen twice a day. Just this morning, she noticed some dried blood on her pillow, and she thinks she may have had a nosebleed. Past medical history includes osteoarthritis and no previous surgeries. She has two adult children who are away at college, and she is divorced. Social History: She drinks two to three glasses of wine each night because she does not like being in the house alone, now that she is an empty-nester. She prefers to drink rather than taking sleeping pills. She was a two-pack-a-day smoker for 20 years until the age of 50. Vitals Signs: Temperature 98.5°F, Pulse 88, Respirations 20, Blood pressure 128/80, BMI 24 Chief Complaint: I noticed small red blood spots on my arms and chest for a few weeks. I noticed blood on my pillow in the morning; I think I had a nosebleed. Address the following: 1. Additional subjective information you would like to ask the patient 2. Objective signs you will be looking for 3. The differential diagnoses that you will be looking at for this patient 4. Your plan of care for the patient—include the information that should be provided to the patient.

Answer 1

1.The additional subjective information which can be collected from the patient are

• complaints of headache,blood in urine,ringing sensation in ear,change in vision or blurred vision,palpitations, ,chest pain ,dizziness,constipation, blood in stool ,fatigue because of naproxen side effects
• Since when she is experienc ing the discomfort

2.The objective signs to be assessed are

• Monitor patients vital as there can be increased heart rate,alteration in Blood pressure, breathing pattern
• Blood sugar to rule out hypoglycemia
• Weight to rule out any weight loss
• Bleeding gums,gingivitis,cancer sores
• Anxiety and clarity while speaking
• Assess the skin for dryness
• Assess for cyanosis in lips and discoloration in eyed

3.The differential diagnosis can be made is

Thrombolytic anaemia (due to breakage of RBC cells and lysis causing petechia on the skin)

4.The plan of care necessary for this patient are

• Change of medication as per the doctors order because patient is experiencing side effects of the drug
• To stop taking alcohol ,because it is an irritant which can further increase the risk of bleeding because of its interaction with the drug
• Monitor the patient's vital signs to assess any changes
• No OTC medication
• To have a nutrious diet to strengthen her bones
• To maintain the same weight ,as over weight can further aggrevate the pain
• Prepare patient for DEXA scan in case of order to rule out loss of bone mass
• Report immediately in case of serious aide effects or unusual symptoms.