Case Study 5 & 6 Knee Injury and Testicular Cancer 

 

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 Knee Injury

 Case Studies

 A 15-year-old gymnast has noted knee pain that has become progressively worse during the past several months of intensive training for a statewide meet. Her physical examination indicated swelling in and around the left knee. She had some decreased range of motion and a clicking sound on flexion of the knee. The knee was otherwise stable. Studies Results Routine laboratory values Within normal limits (WNL) Long bone (femur, fibula, and tibia) X-ray No fracture Arthrocentesis with synovial fluid analysis Appearance Bloody (normal: clear and straw-colored) Mucin clot Good (normal: good) Fibrin clot Small (normal: none) White blood cells (WBCs) <200 WBC/mm3 (normal: <200 WBC/mm3 ) Neutrophils <25% (WNL) Glucose 100 mg/dL (normal: within 10 mg/dL of serum glucose level) Magnetic resonance imaging (MRI) of the knee Blood in the joint space. Tear in the posterior aspect of the medial meniscus. No cruciate or other ligament tears Arthroscopy Tear in posterior aspect of medial meniscus Diagnostic Analysis The radiographic studies of the long bones eliminated any possibility of fracture. Arthrocentesis indicated a bloody effusion, which was probably a result of trauma. The fibrin clot was further evidence of bleeding within the joint. Arthrography indicated a tear of the medial meniscus of the knee, a common injury for gymnasts. Arthroscopy corroborated that finding. Transarthroscopic medial meniscectomy was performed. Her postoperative course was uneventful. 

Critical Thinking Questions 

1. One of the potential complications of arthroscopy is infection. What signs and symptoms of joint infection would you emphasize in your patient teaching?

 2. Why is glucose evaluated in the synovial fluid analysis?

 3. What are special tests used to differentiate type of Tendon tears in the knee ? 

Explain how they are performed (Always on boards)  

 Testicular Cancer

 Case Studies

 A 21-year-old male noted pain in his right testicle while studying hard for his midterm college examinations. On self-examination, he noted a “grape sized” mass in the right testicle. This finding was corroborated by his healthcare provider. This young man had a history of delayed descent of his right testicle until the age of 1 year old. Studies Results Routine laboratory studies Within normal limits (WNL) Ultrasound the testicle Solid mass, right testicle associated with calcifications HCG (human chorionic gonadotropin) 550mIU/mL (normal: <5) CT scan of the abdomen Enlarged retroperitoneal lymph nodes CT scan of the chest Multiple pulmonary nodules Diagnostic Analysis At semester break, this young man underwent right orchiectomy. Pathology was compatible with embryonal cell carcinoma. CT directed biopsy of the most prominent pulmonary nodule indicated embryonal cell carcinoma, compatible with metastatic testicular carcinoma. During a leave of absence from college, and after banking his sperm, this young man underwent aggressive chemotherapy. Repeat testing 12 weeks after chemotherapy showed complete resolution of the pulmonary nodules and enlarged retroperitoneal lymph nodes.

 Critical Thinking Questions 

1. What impact did an undescended testicle have on this young man’s risk for developing testicular cancer? 

2. What might be the side effects of cytotoxic chemotherapy? 

3. What was the purpose of preserving his sperm before chemotherapy?

 4. Is this young man’s age typical for the development of testicular carcinoma? 

 

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Students much review the case study and answer all questions with a scholarly response using APA and include 2 scholarly references. Answer both case studies on the same document and upload 1 document to Moodle.

Case Studies will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 20% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 20%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

 

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Clinical Scenario:

REASON FOR CONSULTATION: Desaturation to 64% on room air 1 hours ago with associated shortness of breath.

HISTORY OF PRESENT ILLNESS: Mrs. X is 73-year-old Caucasian female who was admitted to the general surgery service 3 days ago for a leaking j-tube which was surgically replaced 2 days ago and is now working properly. This morning at 07:30, the RN reported that the patient was sleeping and doing fine, then the CNA made rounds at 0900 and Mrs. X was found be mildly dyspneic. Vital signs were checked at that time and were; temperature 38.6, pulse 120, respirations 22, blood pressure 138/38. O2 sat was 64% on room air. The general surgeon was notified by the nursing staff of the hypoxia, an order for a chest x-ray and oxygen therapy were given to the RN. The O2 sat is maintaining at 91% on 4L NC. The patient was seen and examined at 10:10 a.m. She reports that she has been having mild dyspnea for 2 days that has progressively gotten worse. She does not use oxygen at home. Her respiratory rate at the time of visit was 22 and she feels short of breath. She has felt this way in the past when she had pneumonia. She is currently undergoing radiation treatment for laryngeal cancer and her last treatment was 1 to 2 weeks ago. She reports that she has 2 to 3 treatments left. She denies any chest pain at this time and denies any previous history of CHF. Review of her vital signs show that she has been having intermittent fevers since yesterday morning. Of note, she was admitted to the hospital 3 weeks ago for an atrial fibrillation with RVR for which she was cardioverted and has not had any further problems. The cardiologist at that time said that she did not need any anticoagulation unless she reverted back into A-fib.

REVIEW OF SYSTEMS:

Constitutional:  Negative for diaphoresis and chills. Positive for fever and fatigue.

HEENT: Negative for hearing loss, ear pain, nose bleeds, tinnitus. Positive for throat pain secondary to her laryngeal cancer.

Eyes:  Negative for blurred vision, double vision, photophobia, discharge or redness.

Respiratory: Positive for cough and shortness of breath. Negative for hemoptysis and wheezing.

Cardiovascular: Negative for chest pain, palpitations, orthopnea, leg swelling or PND.

Gastrointestinal: Negative for heartburn, nausea, vomiting, abdominal pain, diarrhea, constipation, blood in stool or melena.

Genitourinary: Negative for dysuria, urgency, frequency, hematuria and flank pain.

Musculoskeletal: Negative for myalgias, back pain and falls.

Skin: Negative for itching and rash.

Neurological: Negative for dizziness, tingling, tremors, sensory changes, speech changes.

Endocrine/hematologic/allergies: Negative for environmental allergies or polydipsia. Does not bruise or bleed easily.

Psychiatric: Negative for depression, hallucinations and memory loss.

PAST MEDICAL HISTORY:

1. Diabetes mellitus that was diagnosed 12 years ago with neuropathy. This resolved after gastric bypass surgery, which she had approximately 3 years ago.
2. Laryngeal cancer
3. Hypertension
4. Hypercholesterolemia
5. Pneumonia
6. Arthritis
7. Hypothyroidism
8. Atrial fibrillation
9. Acute renal failure
10. Chronic kidney disease, stage IV – on 07/30/2013 a renal biopsy was completed, which showed focal acute tubular necrosis and patchy tubular atrophy, moderate to severe interstitial fibrosis with patchy acute and chronic interstitial nephritis, normal cellular glomeruli with no white microscopic evidence of a primary glomerulopathy. Baseline creatinine is 1.9.
11. Peptic ulcer disease
12. Skin cancer
13. Anemia
14. Osteoporosis

PAST SURGICAL HISTORY:

1. Laparoscopic gastric bypass – 3 years ago
2. Closure of mesenteric defect.
3. Radical neck resection on -3 months ago

FAMILY HISTORY:

1. Mother has diabetes diagnosed at age 55 and high blood pressure. She is deceased.
2. Father had heart disease diagnosed at age 60. He is deceased.
3. She had a sister with diabetes, thyroid disease, CKD, on dialysis, with unknown etiology.

SOCIAL HISTORY: She denies any smoking or alcohol use. She denies any drug use.

MEDICATIONS:

1. Calcitriol 0.5 mcg PO every other day
2. Vitamin B12 2500 mcg sublingual every Monday and Thursday
3. Docusate sodium 100 mg PO BID
4. Fentanyl patch 100 mcg every 72 hours
5. Gabapentin 800 mg PO BID
6. Levothyroxine 50 mcg daily
7. Multivitamin 1 PO Daily
8. Oxybutynin 5 mg PO BID
9. Hydrocodone 5/325 1-2 tablets every 6 hours PRN pain

ALLERGIES: SHE IS ALLERGIC TO CIPRO, WHICH CAUSES URTICARIA AND HIVES, CONTRAST DYE, HONEY AND BEE VENOM, ADHESIVE, AND SULFAS, WHICH CAUSE HIVES.

PHYSICAL EXAMINATION:

Vital signs: 38.6, 120, 22, 138/38, 64% on room air. O2 sat of 91 on 4 liters nasal cannula.

Constitutional: She is somnolent. Oriented to person and place. Appears ill and mildly dyspneic.

Head: Normocephalic and atraumatic. Nose: Midline, right and left maxillary and frontal sinuses are nontender bilaterally.

Oropharynx: Clear and moist. No uvula swelling or exudate noted.

Eyes:  Conjunctivae, EOM and lids are normal. PERL. Right and left eyes are without drainage or nystagmus. No scleral icterus.

Neck: Normal range of motion and phonation. Neck is supple. No JVD. No tracheal deviation present. No thyromegaly or thyroid nodules. No cervical lymphadenopathy noted bilaterally.

Cardiovascular: rapid rate, S1 and S2 without murmur or gallop. Brachial, radial, dorsalis pedis, and posterior tibial are 2+/4+ bilaterally.

Chest: Respirations are regular and even with mild dyspnea.

Lungs are coarse and with some rales posterior bases.

Abdomen:  Soft. Bowel sounds are active, nontender, no masses noted. No hepatosplenomegaly noted. No peritoneal signs.

Musculoskeletal: Full range of motion of the bilateral shoulders, wrists, elbows.

Neurologic: Somnolent. Cranial nerves II-XII are intact.

Skin: Warm and dry.

Psychiatric: Mood and affect are normal. Calm and cooperative. Behavior, judgment is intact.

LABORATORIES AND DIAGNOSTICS:

• WBC 7.2, Neutrophil 63%
• Creatinine 2.5 mg/dL, BUN 45 mg/dL, Na 144 mEq/L, Potassium 4.4 mEq/L, Total Bilirubin is 0.9 mg/dL, Platelets 100,000
• BNP 242 pg/mL
• Lactate 1.0 mg/dL
• All other labs are unremarkable
• Chest x-ray: Right lower lobe infiltrate
• EKG: NSR, no ST or T wave changes

One hour after you saw Mrs. X, you get a call from the RN to report that her BP is 75/40 mmHg, heart rate is 140, respiratory rate is 34 and she is dyspneic. Her temperature is 39.6 and she is minimally responsive.  Upon re-evaluation of Mrs. X you note that she is obtunded, struggling to breath, using accessory muscles and O2sats are 85% on a Non-rebreather. Repeat labs are as follows:

WBC 20,000

Hgb 12 g/dL

HCT 36%

Platelets 98,000

Na 148 mEq/L

Chloride 110 mEq/L

Potassium 5.6 mEq/L

Glucose 190 mg/dL

Creatinine 3.0 mg/dL

BUN 68 mg/dL

Albumin 3.0 g/dL

Anion Gap 21  

Lactate 5.2 mg/dL

Procalcitonin 15 ng/dL, INR is 1.0

aPTT 23 seconds

EKG: Atrial Fibrillation with RVR at 156

Questions:

1. What is the most likely cause of her atrial fibrillation with RVR and her pulmonary decompensation?
2. Based on the available clinical data, list all the acute diagnoses. There is a total of 8. Some may be repeated from last week.
3. What additional diagnostic tests should be ordered to further evaluate her cardiopulmonary problems?  
4. Write an assessment and treatment plan for the new cardiac diagnosis, new pulmonary diagnosis, and the electrolyte imbalance. Write a treatment plan which addresses nutrition, stress ulcer and DVT prevention. You should have a complete treatment plan for each disorder. All written orders must have complete instructions. For instance, a medication order must have the name, dose, frequency, and route. Lab orders must include the lab name and frequency. If an order should be done now, stat, urgent or routine that also should be indicated. 
5. What is the most appropriate level of care for this patient?
6. What physician specialty or other interprofessional consults should be ordered?
7. What anticipatory guidance/patient education should you provide to the patient?

 

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Case Study, Chapter 7, Overview of Transcultural Nursing

1. Mrs. Perez, 32 years of age, is a Hispanic patient who is admitted for early stage cancer of the uterus. The surgeon stated that in order to treat Mrs. Perez’s cancer successfully, the uterus will need to be removed surgically through a procedure called a simple hysterectomy leaving the ovaries, fallopian tubes, and vagina. The surgeon requests that the nurse make arrangements for an interpreter, so they can both use the interpreter’s services. The patient only speaks Spanish, but her mother and one of the patient’s sisters are bilingual. They are currently visiting the patient. Her husband is also visiting and he only speaks Spanish. The patient’s two children are with her sister Maria. The family stated they are devout Catholics and request to see a priest while in the hospital. Today is Ash Wednesday. 

1. Which interpreter is the most appropriate choice to communicate with Mrs. Perez and why?
2. After critically analyzing the cultural influences, what nursing actions are appropriate for the patient?

2. The nurse manager of an ambulatory care clinic has noted an increased number of visits by patients from different countries and cultures, including patients from Mexico and other Latin American countries. Concerned about meeting the needs of this culturally diverse population, the nurse manager convenes a staff meeting to discuss this change in patient demographics, and to query the staff about any learning needs they have related to the care of these patients. 

1. What strategy to avoid stereotyping clients from other cultures should the nurse include in this meeting?
2. Identify culturally sensitive issues to be discussed in the staff meeting.
3. One technician on the staff complains that some patients never make eye contact, and this makes it difficult for him to complete his work. How should the nurse respond?

 

 

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