A 49 year-old Hispanic female came into your 24-hr Emergency care clinic complaining of purpuric lesions on her left and right ankles. She stated that she was being treated for rheumatoid arthritis with leflunomide and steroids.

1.What is your initial differential diagnosis? Give at least three. You begin to take a patient history and review of symptoms. She is originally from Venezuela but moved to the United States before Hugo Chavez and Nicolas Maduro came to power, and she has not returned in over nine years. She has lived in South Texas for eight years with her husband and two children. She is not on blood thinners such as warfarin (Coumadin). She denies use of alcohol, tobacco, or illicit drugs. She lives in near the bay but states she has not gone to the beach or been on the water for over five weeks. She has not eaten raw seafood in the last four weeks. She denies any known drug allergies

2a. What conditions might you now exclude?

2 b. Why can you exclude these? The patient had rhinorrhea and myalgia. She stated she had no sore throat, shortness of breath but a sporadic cough, felt no fever or chills, no nausea, vomiting or diarrhea, no abdominal pain, no leg swelling or pain in the extremities. Examination revealed temperature of 38.1°C, heart rate 106 beats per min, BP 126/68 mm Hg, respiratory rate 16 breaths per min, and oxygen saturation of 98%. Lungs were clear on auscultation. Her White blood cell count was 4600/microliter (normal 4500-11,000) lymphocyte count was 700/microliter (normal 1000-4800). Her electrolytes, kidney and liver function tests were within normal range.

3a. Do these findings allow exclusion of some of the differential diagnosis possibilities, and suggest some other possibilities?

3b. What other tests would you perform? The patient was given nucleic acid amplification tests for COVID-19, influenza A, and respiratory syncytial virus—all were negative. She was sent home with fluticasone nasal spray, with the diagnosis of sinusitis. She returned two days later, complaining of shortness of breath. Her oxygen saturation had decreased to 94% .

4. What possibilities must now be considered? List at least four. Radiography of the chest revealed a 5 cm mass in the left lower lobe. A CT scan revealed ground-glass opacity, and some left hilar lymphadenopathy.

5. What conditions from question 4 should be included? Patient now had a temperature of 39oC, complained of a productive cough with green sputum, weakness, nausea and vomiting. The heart rate now increased to 115 beats per minute, BP was 138/85 mm Hg. Auscultation revealed crackles in the left lower lobe. Oxygen saturation dropped to 92% within the two hour wait in the emergency room.

6.a. What are the most likely conditions the patient could have?

b. What should your next steps be with this patient? 2 pts c. What is your final diagnosis?

List the stages of prevention in clinical practice and the stages in public health. Define each and explain the similarities and differences between each level of prevention in public health and its similar stage in clinical treatment. Why are there differences between public health prevention and prevention in clinical treatment?

3. What are the primary components of health policy? How are each deployed and assessed?

A 10-year-old boy presented to a new pulmonary physician for evaluation. His mother stated that his primary condition was asthma. He had developed respiratory symptoms at 2 months of age, had been seen by many specialists, and had been on multiple medications since that time. The pregnancy was uneventful. When he was 2 months old, he developed a recurrent cough. He was started on albuterol and then, at 6 years of age, switched to levalbuterol hydrochloride. At various times he has also been treated with cromolyn sodium, fluticasone proprionate and salmeterol, and montelukast as well as with a short course of prednisolone for exacerbations. His last course of oral steroids was 9 months ago. The hallmark of his illness was that a cold would always trigger his asthma. He had approximately one emergency department visit per year, but he had never been hospitalized. His asthma symptoms would typically worsen with the weather changes in the spring and fall; the cold winter months were often particularly difficult. In addition to his asthma, his medical history was remarkable for several events of otitis media, seasonal mold allergies, occasional headaches, and croup. One or more of the events occurred about three times a year, lasting approximately 3 days for each episode. His current medications include 1 inhalation of com- bination fluticasone proprionate and salmeterol in the 250/50 strength twice daily and 2 to 4 inhalations of levalbuterol as needed. This visit was scheduled in the hopes of decreasing this child’s episodes of illness, assessing the current medication regimen, and discussing new treatment opportunities.

1. What role does fluticasone proprionate and salmeterol serve in controlling this child’s asthma symptoms?

Nicole had been coding inpatient accounts for many years. She was not certified but was the “go‐to”
coder for any questions from her colleagues. She was encouraged many times to take her certification
test, but she knew how she felt about tests – she had a great disdain for anything timed! One day,
her manager, Vickie, told her she needed to take her test within the next three months as the hospital
was now requiring certification of all coders working for them. Nicole signed up to sit for her Certified
Coding Specialist (CCS) test. She studied a little. She was sure she knew the answers to the questions.
The more she studied, the more anxious she became. On the day of the test, she worked hard at
keeping her anxieties and fears under control. When she started to take the test she was
overwhelmed. She finished the test to the best of her knowledge. When Nicole walked out of the
testing center, she had her results – she failed.

1. If you were Nicole's manager, what would you suggest she do prior to taking the exam?

2. What resources should she use for studying?

3. If you were Nicole's close friend and fellow coder, and she told you she failed the exam, what would
you tell her? What would you suggest?

Give at least 5 important nursing considerations you need to focus in the care of client 24-48 hours after normal delivery.

A 9-year-old female with cystic fibrosis presented to the pulmonary clinic with persistent exertional dyspnea and cough with scant sputum production. Physical assessment revealed normal vital signs, but she had an oxygen saturation of 91% while breathing room air. Her weight had fallen from 68.2 kg to 65.5 kg over the last 3 months. Cardiovascular assessment was completely normal. Lungs demonstrated coarse breath sounds bilaterally and were moderately decreased. The abdomen was normal, extremities demonstrated mild clubbing, and there was no peripheral edema. FEV1 had decreased from 70% to 50%. The chest radiograph resembled baseline findings with no obvious infil- trate or pneumothorax. Her standard inhaled treatment regimen was albuterol, 7% hypertonic saline, dornase alfa, and Flovent followed by vest therapy twice daily. She was prescribed a month-long course of azithromycin, aztreonam, and inhaled tobramycin for suspected pulmonary exacerbation with an acute superinfection. One month later she returned to the clinic for a follow-up visit. Physical exam re- vealed moderate improvement in dyspnea as well as her FEV1, which now was back to baseline, and her oxygen saturation improved to 95% on room air.

1. Why do you think multiple antibiotics were prescribed for this child?

A 9-year-old female with cystic fibrosis presented to the pulmonary clinic with persistent exertional dyspnea and cough with scant sputum production. Physical assessment revealed normal vital signs, but she had an oxygen saturation of 91% while breathing room air. Her weight had fallen from 68.2 kg to 65.5 kg over the last 3 months. Cardiovascular assessment was completely normal. Lungs demonstrated coarse breath sounds bilaterally and were moderately decreased. The abdomen was normal, extremities demonstrated mild clubbing, and there was no peripheral edema. FEV1 had decreased from 70% to 50%. The chest radiograph resembled baseline findings with no obvious infil- trate or pneumothorax. Her standard inhaled treatment regimen was albuterol, 7% hypertonic saline, dornase alfa, and Flovent followed by vest therapy twice daily. She was prescribed a month-long course of azithromycin, aztreonam, and inhaled tobramycin for suspected pulmonary exacerbation with an acute superinfection. One month later she returned to the clinic for a follow-up visit. Physical assessment revealed moderate improvement in dyspnea as well as her FEV1, which now was back to baseline, and her oxygen saturation improved to 95% on room air.

1. What is the mechanism of action of dornase alfa?

A comfortable environment will be individual to the particular client that you are providing care and support for. Give details of a specific time that you altered an environment for a client in order to make them feel comfortable.

It is essential to respect clients’ individual differences. Give examples of the different ways that you can do this to maintain their dignity and privacy whilst providing them with support.

Managing Change

Jennifer Kowal, a family nurse practitioner, moves to a small rural community in Michigan. There is no primary health care office within a 50-mile radius. She decides that she will open a community health center and provide primary care services. Nurse Kowal has never managed or owned a business. She has negotiated a collaborative agreement with a family practice physician in a major urban area. Nurse Kowal begins to review the literature on best practices in primary care settings.

1. What activities should Nurse Kowal undertake before opening the health center?
2. Nurse Kowal’s dad is a prominent business owner in the city she grew up in. When she tells him what she is trying to do, he asks what her mission statement and business vision are. When she tells him, he warns her, “That’s all very well, but make sure you build in a way to be flexible, too.” If Nurse Kowal’s core purpose and core values will be unchanging, how can she keep her organization flexible as well? Is it possible her father is wrong because he does not understand how health care must work?