primary care of adults across the lifespan€¦ · family med hx: both parents are deceased. father...

Running head: PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 1

Primary Care of Adults across the Lifespan

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PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN 2

NURS 6531 WK 6

Practicum Experience Journal

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Subjective

CC: Abdominal pain, bloating, nausea, difficulty swallowing, hoarsens, and a tight, swollen

stomach. The patient also reports to a weight loss of17.2 Ibs over the past three months.

L = stomach

O= stomach discomfort over the last three months

C= tight swollen stomach.

A= Abdominal pain bloating, nausea, difficulty swallowing, 17.2Ibs weight loss.

T= discomfort present all the time

E= Nothing relieves the pain

S= Mild pain ranging 6/10

HPI: A 46-year-old African -American female presents to the clinic with abdominal pain,

bloating, nausea, difficulty swallowing, hoarsens, and weight loss over the past three months.


The patient has a history of GERD that has been well controlled with Omperazole and

Ranitidine. She denies any diarrhea, vomiting blood, or bloody stools.

PPMH: Has a history of GERD. No previous hospitalizations.

PSH: No past medical surgeries.

Family Med Hx: Both parents are deceased. Father had a history of hypertension. Mother had a

history of diabetes and hypertension.

Social Hx: Single mother of five children. Smokes a packet a day, non-drinker and has used

marijuana in the past. She performs physical exercise but not regularly. She is a member of the

Baptist faith. Reproductive/Sexual: Denies sexual activity in the past two years.

Allergies: Has a penicillin allergy

Immunizations: Current on all immunizations but has not yet received an influenza vaccine.

Medications: Omperazole 20MG 1 tab in AM, Ranitidine 150MG BID

SUBJECTIVE

ROS:

General: No reported fever or rashes. Has lost 17.2 Ibs over the past three months.

Neuro: generalized weakness. Reports no head ache, dizziness, and confusion or memory

problems.

HEENT: Reports hoarseness. Denies visual changes, headache, sinus pressure, ear pain, throat

pain. Respiratory: Denies any respiratory complications.


Cardiovascular/Peripheral Vascular: Denies any chest pain, palpitations or edema.

Gastrointestinal: Abdominal pain, bloating, nausea.

Genitourinary: Does not report any changes in the urinary pattern. No rashes or complications in

the genital areas.

Musculoskeletal: Does not report any joint pains, difficulty in coordination, or mobility

problems.

Skin: Denies the presence of rashes or lesions.

OBJECTIVE

Vital signs: Temp 98.6, HR 90 BPM, BP 103/67 mm HG, O2 100% RA, Weight, 48.63 Kg BMI

18.99 Index

General: Well developed, pleasant, and cooperative.

Neurologic: Non-focal.

Psychiatric: Alert, oriented, cooperative with the exam. Appropriate mood, and affect. Can

answer most questions and have no memory problems.

Skin: No suspicious lesions or rashes.

Hair: Normal texture, thinning, and distribution.

Nails: Brittle nail with a whitish color.

HEENT: Head: No headache, no masses. Eyes: No tearing, clear conjunctiva, normal eye color.

Ears: No observable lesions or rashes, no abnormal discharge. Nose: No observable lesions or


abnormal mucus production. Mouth: Mucosa is moist with no mucosal lesions. Teeth/Gums:

Missing several molars. Hoarsens in the patient’s voice.

Neck: Supple, full range of motion, no cervical lymphadenopathy.

Chest: Chest symmetrical, symmetrical expansion. No nipple deformity. No accessory muscle

use. No masses or tenderness to palpation.

Lungs: Clear A/P bilaterally on auscultation.

Abdomen/GI. Distended, hyper bowel sounds with a lot on gurgling, non-tender on palpation,

unable to palpate liver margin.

Musculoskeletal: Normal.

Hematologic: Absence of edema or bleeding complications.

Endocrine: weight loss of 17.2 Ibs for the past three months. No noticed fever, chills, or

excessive sweating.

Diagnostics:


To determine the diagnosis for the patient, in this case, we performed a blood cell count

on a sample of blood collected from the patient. The results indicated neutropenia, moderate

anemia. We also performed a urine test which indicated hypokalemia.

For further diagnosis, the patient will undergo an esophagogastroduodenoscopy (EGD).

The procedure involves using a thin, flexible tube inserted through the mouth and pushed

through the pharynx, esophagus, stomach, and duodenum (Buie, Campbell, Fuchs, Furuta, Levy,

VandeWater, & Carr, 2014). The endoscope uses a charged video chip for better imaging inside

the gastrointestinal system (Buie et al., 2014). It is used while the patient is conscious or under

moderate sedation (Buie et al., 2014). An EGD is used to diagnose upper gastrointestinal

diseases, surveillance of upper gastrointestinal cancer, or for therapeutic purposes (Buie et al.,

2014).

We will also send the patient for a colonoscopy. A colonoscopy is a medical procedure

that investigates the inside of the large intestines (Buie et al., 2014). It is used to check for

symptoms of intestinal bleeding and abdominal pain discomfort (Buie et al., 2014). A

colonoscopy can also be used to check for cancer (Buie et al., 2014). The procedure is performed

using a long flexible tube that provides an image of the walls of the colon (Buie et al., 2014). The


tube is inserted through the rectum and pushed to the other parts of the large intestine (Buie et

al., 2014). A colonoscopy takes place under general anesthesia or when the patient is still

conscious (Buie, et al., 2014).

Other diagnostic procedures that can be performed for the patient, in this case, include

computerized tomography (CT) scan. This is a combination of x –rays and computer technology

performed to provide an image for the inside of the esophagus and stomach (Buie et al., 2014).

The procedure allows the doctor to visualize any abnormalities. An esophageal manometry test

can also be used to measure the strength and coordination of the esophageal muscles (Buie et al.,

2014).

Further lab tests may also include a urea breathe test. The procedure involves giving a

liquid that contains urea to the patient (Buie et al., 2014). The patient takes the liquid, and if she

has H.pylori bacteria, the bacteria will break down the urea in carbon dioxide (Buie et al., 2014).

The carbon dioxide appears in the patient’s breath when she exhales (Buie et al., 2014). The

physician takes a sample of the breath and sends it to the lab for sampling (Buie et al., 2014).

High levels of carbon dioxide indicate H.plori bacteria (Buie et al., 2014). A stool test may also


be used to check for the presence of H.Pylori bacteria (Buie et al., 2014). The doctor collects a

sample of the patient’s stool and sends it to the lab for analysis (Buie et al., 2014).

Assessment:

Primary Diagnosis:

Gastric cancer. Gastric cancer is a condition in which cancer cells form in the stomach

lining (Correa, Haenszel, Cuello, Tannenbaum, & Archer, 2015). The stomach contains walls

that are made up of five layers: the mucosa, sub mucosa, connective tissues, and serosa (Correa

et al., 2015). When an individual acquires gastric cancer, it starts from the mucosa and spread to

the outer layers (Correa et al., 2015). The risk factors for gastric cancer include having a

gastrointestinal condition, eating highly salted or smoked foods, and smoking (Correa et al.,

2015). Being older and having a family history of stomach cancer may also increase the risk of

gastric cancer (Correa et al., 2015). The symptoms of gastric cancer manifest depending on the

stage of the disease (Correa et al., 2015). Early symptoms include stomach discomfort, bloating,

nausea, loss of appetite, hoarseness, and heartburn (Alberts, Cervantes, & Van de Velde, 2015).

Later stages symptoms include stomach pain, trouble swallowing, abnormal weight loss,


vomiting, blood in the stool, and a buildup of fluid in the stomach (Alberts et al., 2015). I

selected gastric cancer as the primary diagnosis because the patient, in this case, showed most

symptoms discussed above. The symptoms were difficulty swallowing, stomach pain, bloating,

nausea, abnormal weight loss, hoarseness, and a tight, swollen stomach. Though the patient did

not show some of the symptoms such as bloody stools and vomiting, she is most likely suffering

from gastric cancer. Another reason why I selected gastric cancer was that the patient has a

history of gastroesophageal reflux disease (GERD), which increases the chances of acquiring

gastric cancer. The lab results also indicated anemia and neutropenia, which are also signs of the

presence of cancer. However, the diagnosis might not be accurate, and further lab tests are

needed to determine the exact diagnosis.

Differential Diagnosis:

Barrett’s Esophagus. This is a gastrointestinal condition that replaces the tissues in the

esophagus with tissues similar to the intestinal lining (Spechler & Goyal, 2016). Symptoms

include difficulty swallowing, stomach discomfort, nausea, heart burn, vomiting, and less

commonly, chest pain (Spechler & Goyal, 2016). There is no known exact cause of Barrett’s

esophagus, but having a history of gastroesophageal reflux disease (GERD) may increase the


chances of acquiring the disease(Spechler & Goyal, 2016). In GERD, stomach contents go back

to the esophagus damaging the esophagus tissue (Spechler & Goyal, 2016). Other risk factors of

Barrett’s esophagus are being old, smoking, excessive weight, being white, and having chronic

heartburn or acid reflux (Spechler & Goyal, 2016). Barrett’s’ esophagus may increase the risk of

esophageal cancer if it is not treated (Spechler & Goyal, 2016). The patient, in this case, might

be having Barrett's esophagus because she has a history of GERD. The patient also showed some

symptoms of the disease, such as difficulty swallowing, nausea, and stomach discomfort. Further

laboratory tests are needed to determine the diagnosis.

Peptic ulcers. These are sores that occur in the inside lining of the upper portion of the

small intestine and the stomach (Ramakrishnan & Salinas, 2017). They are commonly caused by

H.pylori bacteria or the long-term use of non-steroidal anti-inflammatory drugs (Ramakrishnan

& Salinas, 2017). Symptoms include stomach pain, bloating, nausea, heart burn, unexplained

weight loss, changes in appetite, and vomiting (Ramakrishnan & Salinas, 2017). The patient, in

this case, could be having peptic ulcers because she showed symptoms such as nausea,

unexplained weight loss, nausea, and bloating. However, further lab tests and an investigation on

the patient's lifestyle and medical history should be done to confirm the diagnosis.


Hiatal hernia. The diaphragm has a small opening known as the hiatus through which the

esophagus passes to connect with the stomach (Ellis, Crozier, & Shea, 2016). If an individual

has hiatal hernia, the stomach bulges through the hiatus into the chest (Ellis et al., 2016). A small

bulge usually does not cause compilations, but a large one allows food and acid back to the

esophagus, which might cause complications (Ellis et al., 2016). Symptoms of hiatal hernia

include heartburn, difficulty swallowing, abdominal pain, breath shortness, vomiting, and acid

reflux (Ellis et al., 2016). Though the patient, in this case, showed a few symptoms of hiatal

hernia, the diagnosis can only be confirmed after further lab analysis.

Indigestion. Indigestion is a term used to refer to upper abdomen discomfort. Indigestion

is not a disease but a symptom in which one experiences a feeling of fullness and abdominal pain

(Puylaert, 2017). Though indigestion is common, different people experience indigestion

differently, and the symptoms may be felt occasionally (Puylaert, 2017). Indigestion can be an

indicator of another digestive disease; thus, medical intervention is necessary (Puylaert, 2017).

The symptoms of indigestion include stomach discomfort, bloating, nausea, and hear burn. Less

common symptoms include vomiting and belching (Puylaert, 2017). The patient, in this case,


may be having indigestion but may also have other stomach compilations. Further diagnostic

tests are needed to determine her diagnosis.

Plan:

Medication discontinued: N/A

Medication started: N/A

Alternative therapies: The patient, in this case, is suspected of having cancer. Before starting

treatment, we will conduct various tests to confirm the diagnosis and to determine the stage of

cancer. However, while waiting for the results, various interventions will be used to improve the

quality of life of the patient. We will work with the patient to determine the best interventions

for her symptoms. The patient is likely to experience stress when she learns about her diagnosis.

To manage stress, we will recommend meditation, music therapy, or various relaxation

techniques to reduce anxiety. Physical exercise can also be used to manage patient stress and

improve her general quality of life (Lamb, Brown, Nagpal, Vincent, Green, & Sevdalis, 2014).

Therefore, we will work with the patient to create a regular exercise plan.


Health promotion strategies: The patient and her family need to understand the importance of

adhering to treatment and attending all the doctor's appointments. We will first educate her on

the importance of strictly following all medical recommendations. We will also educate her and

her relatives on how to keep appointment reminders. The patient may also require dietary

changes; thus we will create a nutritional with for the patient to ensure she consumes a healthy

diet. Some of the priority food that will be recommended include high protein foods such as soy

foods, fish, and nuts. Carbohydrates are also important for physical activity and proper organ

function. Sources of carbohydrates include fruits, vegetables, and whole grain foods. Foods rich

in vitamins and minerals such as vegetables are also a requirement in cancer patients. The

patient will also need to take eight glasses or more of liquid each day.

Diagnostic tests ordered: The patient has been scheduled for a colonoscopy and

esophagogastroduodenoscopy (EGD) for further assessment. The results are expected in two

weeks' time. If the results confirm a cancer diagnosis, we will perform further lab procedures to

determine the stage of her cancer. Some procedures that may for cancer staging include

endoscopic ultrasound, PET scan, CAT scan, MRI, and laparoscopy (Alberts et al., 2015). The


staging procedures will be performed within the first week after the confirmation of the

diagnosis.

Disease prevention strategies: Various treatments can be used in the treatment of gastric cancer.

We will evaluate the various treatment options before selecting the most suitable for this case.

The treatment option selected will also take into consideration the facilities available in the

facility. Some procedures that we might use for treatment will include the following:

Surgery. Surgery can be used to treat gastric cancer. There are two types of surgeries. Subtotal

gastrectomy and total gastrectomy (Alberts et al., 2015). A subtotal gastrectomy involves the

removal of the part of the stomach that contains cancer and other tissues and organs near the

tumor (Alberts et al., 2015). A total gastrectomy, on the other hand, requires the removal of the

entire stomach and other tissues surrounding the tumor (Alberts et al., 2015).

Endoscopic mucosal resection. An endoscopic mucosal resection uses an endoscope to remove

precancerous growths and early stage cancer from the lining of the digestive tract (Alberts et al.,

2015). The procedure does not require surgery.


Chemotherapy. This is a form of treatment that uses drugs to stop the spread of cancer cells

(Alberts et al., 2015). Chemotherapy works by either killing the cells or stopping them from

multiplying (Alberts et al., 2015). The drugs are taken by mouth or injected into the blood stream

and can reach cancer cells found in the body (Alberts et al., 2015).

Radiation Therapy. This is a form of cancer treatment that uses radiation to kill cancer cells or to

prevent them from growing (Alberts et al., 2015). There two forms of radiation therapy; external

radiation therapy and internal radiation therapy. External therapy uses a machine outside the

body to send radiation to cancer (Alberts et al., 2015). Internal therapy uses radioactive

substances such as wires or seeds that are placed directly on cancer (Alberts et al., 2015).

Immunotherapy. A treatment that utilizes the patient's immune system to fight cancer. A

substance made in a laboratory or by the body is used to defend the body against cancer.

Targeted therapy. A form of cancer treatment that uses drugs or other substances to attack

particular cancer cells without harming normal cells (Alberts et al., 2015).

Chemo radiation. A combination of radiation and chemotherapy to kill cancer cells or prevent

their growth (Lamb et al., 2015).


Referrals: We have consulted the hematology and oncology for possible urgent care and

treatment for the patient. We will also refer the patient to a mental health practitioner to offer

psychological support to the patient. We might also refer the patient to a nutritionist who will

work with the patient to optimize the patient’s nutritional results. A support group and a spiritual

group may also be necessary to improve the patient’s quality of life.

Follow up: The patient is required to visit the clinic every week for close monitoring of her

symptoms and provide immediate interventions if needed.

Reflection:

This week's tasks allowed me to understand the implications of different gastrointestinal

symptoms. I was surprised to learn that some symptoms such as abdominal pain and bloating are

usually ignored, but they may be indicators of serious medical complications such as cancer. I

also learned that some gastrointestinal complications such as gastro esophageal reflux disease

should be treated as soon as they are detected because they can lead to serious complications. I

also learned that neutropenia and anemia are symptoms of cancer. I also understood various

diagnostic procedures such as endoscopy and a stool test that can be to assess gastrointestinal


symptoms. The experience also allowed me to acquire knowledge of different forms of cancer

treatment. I also came to understand the importance of collecting a thorough patient history

during diagnosis. In future practice, I will apply the skills obtained from this experience when

providing care to other patients.

________________________

Preceptor Signature and Date


References

Alberts, S. R., Cervantes, A., & Van de Velde, C. J. H. (2015). Gastric cancer: epidemiology,

pathology, and treatment. Annals of Oncology, 14(suppl_2), ii31-ii36.

Buie, T., Campbell, D. B., Fuchs, G. J., Furuta, G. T., Levy, J., VandeWater, J., ... & Carr, E. G.

(2014).Evaluation, diagnosis, and treatment of gastrointestinal disorders in individuals

with ASDs: a consensus report. Pediatrics, 125(Supplement 1), S1-S18.

Correa, P., Haenszel, W., Cuello, C., Tannenbaum, S., & Archer, M. (2015). A model for gastric

cancer epidemiology. The Lancet, 306(7924), 58-60.

Ellis, F. H., Crozier, R. E., & Shea, J. A. (2016). Paraesophageal hiatus hernia. Archives of

Surgery, 121(4), 416-420.


Lamb, B. W., Brown, K. F., Nagpal, K., Vincent, C., Green, J. S., & Sevdalis, N. (2014). Quality

of care management decisions by multidisciplinary cancer teams: a systematic

review. Annals of Surgical Oncology, 18(8), 2116-2125.

Puylaert, J. B. (2017). Ultrasonography of the acute abdomen: gastrointestinal

conditions. Radiologic Clinics, 41(6), 1227-1242.

Ramakrishnan, K., & Salinas, R. C. (2017). Peptic ulcer disease. American Family

Physician, 76(7).

Spechler, S. J., & Goyal, R. K. (2016). Barrett's esophagus. New England Journal of

Medicine, 315(6), 362-371.

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