Clinical Immunology Essay Assignment Paper

Clinical Immunology Essay Assignment Paper

6/21/2020 FNP Student H&P 11:00 Note the date, time, and fact that this is a FNP-S student note are clearly labeled.

CC: Mr. Jones is a 72yo white, retired farmer, who presented to the ER because “I fainted 3 times in the last 2 days.” CC is specific, gives key pt demographics, and duration of cc. If he’d had a h/o CAD or CVA, you could include that here.

HPI: Mr. Jones was in his usual state of health, which allows him to lead a fairly active life, until 2 days PTA when he was in the kitchen making a sandwich. At that time he felt “dizzy” and found himself on the floor. He described the dizziness as “feeling like he was going to pass out.” He doesn’t remember what happened but thinks he lost consciousness for only a few seconds to minutes. No one was home at the time to witness it. He had a headache after the episode, which he relates to hitting his head. (It has eased off with Tylenol.) Prior to losing consciousness, he did not experience a headache, chest pain, palpitations, or shortness of breath. He was not incontinent. Other than the headache, he felt fine and ate his sandwich once he “came to.” Clinical Immunology Essay Assignment Paper

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He had a very similar episode the next day while he was sitting down watching TV. He felt like he was going to faint and then became aware that he had missed part of his show. The 3rd fainting spell occurred this morning as he was getting out of bed. He fell back onto the bed so did not hurt himself. He told his wife what happened and she insisted that he come to the ER.

The chronology is very clear and descriptions are specific. The information is presented as a story. The question ‘why seek help now’ is clearly addressed. (‘Usual state of health’ alone can be misleading if a patient is usually in poor health. Notice the brief elaboration.)

He has not started any new medicines or engaged in any new activities lately. He has not been sick including no N/V/D. He has never had chest pains or been told he has heart disease. He has had vertigo in the past but that was very different from his current “dizziness”. He has not had any change in vision, slurred speech, weakness, numbness, or tingling in the last week.

Pertinent positives and negatives are in a separate paragraph, CAN be one large paragraph

He still likes to ride his tractor and do light farming but is afraid to since these episodes started. He is also afraid to drive as it could happen then and cause an accident.

The effect of the problem on the patient’s life is addressed.

PMH:

1. COPD- smoked 2 ppd for 40 years, quit 1987.
2. HTN- usually runs 130s/80s, per patient
3. Pneumonia- hospitalized for 3 days in 1996 (received pneumovax then)
4. Osteoarthritis of hips, knees, and hands Clinical Immunology Essay Assignment Paper
5. Gout
6. BPH
7. Diverticulitis 1988- last colonoscopy 2000 w/ 2 polyps
8. Appendectomy 1965
9. Right inguinal hernia repair 1982

Operations can be listed separately under Past Surgical History (PSH)

Medications

1. lisinopril 20 mg po daily, for HTN
2. ASA 325 mg po daily, for cardioprotection
3. Allopurinol 300mg po daily, for gout prevention
4. Atrovent 2puffs 4 times a day, for COPD
5. Motrin 200mg po 2-3 times a day as needed for arthritis
6. Aleve 1-2 tabs po 2-3 times a day as needed for arthritis
7. Tylenol arthritis 1-2 tabs po 3-4 times a day as needed for arthritis
8. Saw palmetto 2 tabs po daily, for prostate

You are strongly encouraged to include the reason for each medication. It is also interesting to learn why patients think they are taking certain medications.

Allergies– sulfa (rash)
Adverse drug reactions- codeine (N/V)

Drug reactions are clearly separated from the true allergies.

FHx-

Father killed in WWII
Mother-HTN and DM, died age 75 of heart attack Sister- 75 and healthy
Brother – 70 with heart problems and emphysema Brother- died at 68 of heart attack
Son- 47, healthy

The health of all 1st degree relatives is addressed. Clinical Immunology Essay Assignment Paper

SHx- Married 50 years this Oct; retired corn and tobacco farmer but still maintains about 3 acres of grazing pasture and a small vegetable garden himself; High School grad; served 1 year in Korea (Army). One son and 3 grandchildren who live nearby. He keeps 2 horses for them but doesn’t ride himself anymore. Tobacco- as above, ETOH- 2 beers/day for about 20 years but now only an occasional beer every month; no other drugs; monogamous w/ wife.

The SHx provides a clear sense of what the patient’s lifestyle is like, including activity level and support system. Habits are detailed but there is no redundancy, e.g. tobacco history was already addressed in the HPI.

ROS– Cough- chronic, mostly in the morning, productive of a small amount of white phlegm
low back pain- chronic and worse at the end of the day
nocturia- gets up 3-4 times a night, worse over past year

Given your stage of training, we want you to include everything you ask in the ROS, including the negatives. This is perfectly acceptable. This guideline is meant to reflect what an experienced clinician does in practice, so you can apply it to all stages of your career. Found in bates; but if you don’t ask about it; don’t chart it. Should be complete ROS from bates – specific to the patient you are seeing.

PE- Thin, alert, elderly white man with a purple-red nodule above the left eye who is sitting up on the stretcher breathing comfortably and appears neither acutely nor chronically ill. Clinical Immunology Essay Assignment Paper

General description is specific.

Vitals- T 97.8 BP 105/40, supine, 100/40; standing P 56, regular, supine; 52 standing R 22, unlabored, O2 sat- 93% (RA)

Pertinent details of the vitals are included.

Head- 3cm, tender, round, purple-red nodule above left eyebrow, skin intact, no surrounding erythema; Eyes- PERRL; fundi- limited exam secondary to hazy, brown opacities obscuring retina
Ears- both ear canals impacted w/cerumen

Nose- nares patent w/o edema or D/C
Mouth/throat- edentulous, moist mucosa w/o lesions Neck- supple, thyroid nonpalpable, no LAD
Back- spine straight w/o point tenderness, lumbar paraspinal muscles tight w/ diffuse tenderness
Lungs- hyperresonant, diminished BS throughout, I:E ratio 1:3, no wheezes or crackles CV- carotids 2+ w/o bruits, JVP 5 cm, heart bradycardic, regular S1, S2 w/ II/VI holosystolic murmur at apex radiates to axilla; rad pulses 2+, fem pulses 1+w/ rt bruit, DP 1+ left, nonpalp right
Abd- scaphoid, normoactive bowel sounds, soft, NT; liver 7 cm by percussion, spleen nonpalp, no masses or bruits
Rectal- normal sphincter tone, brown heme neg stool, large, firm prostate w/o nodules or asymmetry (per ER resident)

Sometimes certain parts of the exam that are sensitive like GU and pelvic have already been performed by the time you see the patient and the patient declines to have them repeated. In this situation, you still include any findings but note that you did not personally perform that portion of the exam. You should still ALWAYS try to perform these parts of the exam yourself with a chaperone.

Ext- clubbing, no edema, hair loss on feet to mid calf but warm w/o cyanosis, Heberden’s nodes on 2nd-5th digits of both hands, knees enlarged w/o effusion, warmth, or erythema but crepitations bilaterally, hips NT w/ FROM
Neuro- MMSE 29/30 (forgot one object), CN 2-12 intact except diminished hearing to finger rub bilaterally, BC>AC on Rinne test, sensation intact to pinprick, vibration, and light touch in all 4 ext, strength 5/5 bilaterally delts, biceps, triceps, wrist ext, hand grip, hand intr, psoas, quads, tib ant, EHL, gastroc; muscle bulk and tone normal; no pronator drift, fine motor normal, Romberg absent; coordination: FTN and HTS normal, gait slightly broad based but steady; DTRs 2+ bicep, tricep, brachrad and 1+ patella, Achilles absent; Babinski absent;

Skin- leathery w/ marked wrinkles on face and neck, multiple brown papules 1⁄2-1 cm w/ regular boarders that appear “stuck on” scattered on back, scaly erythematous macules scattered on forearms, dorsum of hands, and one on right temple and one behind left ear Clinical Immunology Essay Assignment Paper

Descriptions in the PE are consistently specific, vague terms are avoided.

You know exactly what the examiner did and did not perform.

(as you are the examiner)

Lab data /Diagnostic studies

Hgb- 12.5 (13.5 in 1999)
WBC- 5.0 (P50%, L40%, M10%)

glc- 168

(creat 1.0 in 1999, CO2 32 in 1999)

Ca- 8.2, Mg 2.0, PO4 3.2 U/A- trace glucose and protein, no RBC’s or WBC’s, nit. neg.

Pertinent old lab data is included.

Plts- 425,000 MCV- 70

CXR- hyperinflated lung fields with rounded opacity in RUL, decreased alveolar markings apices> bases, no cardiomegaly (formal radiology report pending).

ECG- sinus bradycardia, rate 56 w/ RBBB pattern, rt and left atrial abnormality, one ectopic beat, and 3mm Q’s in III and aVF

Problem list /Differentials

Student provides own interpretation.

The problem list is complete, prioritized, and specific w/o being redundant or too detailed. There is subjectivity to the specific prioritization, but the most urgent issues are at the beginning starting with the cc and the least urgent issues are at the end. Clinical Immunology Essay Assignment Paper

1. Syncope
2. Head trauma
3. Possible lung mass
4. ECG w/ RBBB, ectopy, and evidence of likely old MI
5. COPD
6. Microcytic anemia
7. Hyperglycemia
8. Renal insufficiency
9. HTN
10. Nocturia, recently increased w/ trace glucose and protein on U/A
11. PVD
12. LBP
13. OA
14. BPH
15. Elevated CO2, chronic and likely secondary to CO2 retention from #5
16. Polypharmacy

Assessment/Plan:

Mr. Jones is a 72yo man w/ 2d h/o syncope that is acute in onset, not positional, and is in the setting of an abnormal ECG, all of which is concerning for an arrhythmia.

There is a summary statement that reiterates the cc and key related features, followed by a definite commitment to an impression.

1. Syncope from probable arrhythmia- cardiac etiology such as sick sinus syndrome or VT is compatible with history. Although he hasn’t had CP, he has many cardiac risk factors (age, sex, FHx, tobacco, and possible diabetes) and could have had an MI to precipitate this. More likely an MI would be old, given the lack of symptoms but an acute coronary syndrome (ACS) can’t be ruled out at this point. A neurologic process like vertebro-basilar insufficiency could cause syncope and he has evidence of vascular disease on exam. However, the lack of focal neurological signs or symptoms makes this less likely. He lacks incontinence or post-ictal confusion to suggest seizure. Finally the possible lung mass and significant tobacco history raise the possibility of lung cancer and possible CNS met. But again, lack of focal symptoms or headache preceding the fall makes this less likely. Orthostasis is a common cause of syncope in the elderly but his history and PE aren’t compatible, despite being on Hytrin. Clinical Immunology Essay Assignment Paper

Notice how the differential diagnosis is woven into the discussion of the assessment. Critical features of the history, PE, and lab data are noted. The amount of space devoted to the explanation of the various differentials is proportional to their relative likelihood. Unlikely diagnoses are only mentioned. Very rare possibilities are not addressed.

Check troponin, admit to tele bed, consult cardiology for possible EP study, ECHO to assess for LV dysfunction and wall motion abnormalities to suggest prior infarct (and nidus for arrhythmia), fasting lipids in AM for risk factor modification

1. Head trauma – risk of subdural but no focal findings or headache now, consider CT or MRI if change in neuro status or cardiac w/u for syncope unrevealing
2. Possible lung mass concerning for malignancy given the extensive smoking history and clubbing. Consider CT scan.
3. Microcytic anemia w/ thrombocytosis suggestive of Fe deficiency anemia. Stool heme neg but GI bleed would still be most likely source particularly given multiple NSAIDS. Check Fe panel, hemocult stools, monitor Hgb, and avoid NSAIDS. If stable can w/u as outpatient. If Hgb decreases, consider EGD to eval for PUD
4. Hyperglycemia- concerning for diabetes given recent increase in nocturia, monitor glucose, and add insulin if needed for glucose control, consider checking HgbA1c if persistently elevated glucose
5. Renal insufficiency- unclear chronicity but new since 1999; likely multifactorial given HTN, possible diabetes and NSAIDS. Once patient weighed will calculate estimate of creat cl and renally dose drugs, maintain good BP control and cont. ACEI but will d/c NSAIDS as above
6. COPD- clinically stable, continue Atrovent MDI
7. HTN- well-controlled, cont. lisinopril
8. Nocturia- likely secondary to BPH and may be exacerbated by hyperglycemia.
9. Prostatitis possible but no tenderness on exam. No symptoms to suggest UTI. Will check U/A for glucose and signs of infection. Check postvoid residual. Cont. Hytrin for now as has tolerated in past (also may be helping maintain good BP control)
10. BPH- possibly worsening, will make sure no urinary retention, cont. meds (except saw palmetto as nonformulary)
11. Chronic CO2 elevation- likely compensatory secondary to chronic CO2 retention and respiratory acidosis from COPD, not acute problem but will be careful giving high levels of O2 if hypoxia develops and consider ABG.
12. Polypharmacy- will educate about OTC’s and redundancies of NSAIDS
13. DVT risk- he’s on bedrest so will prophylax w/ heparin 5000U SQ bid
14.  F/E/N- (fluids/electrolytes/nutrition)- he appears euvolemic so no IVF and low fat diet, consider diabetic diet if fasting glucose elevated. Clinical Immunology Essay Assignment Paper

The plan is listed immediately after each problem. But, it is equally correct to list all your assessments in one section and then have a separate section devoted entirely to the plan. It is a matter of personal choice. Often you will be unsure of the plan but you still should try to come up with a plan. In these cases, use the word ‘consider’. This allows you to demonstrate your thought processes without having something potentially erroneous or misleading in the medical record.

#13 and 14 are commonly included in A/P for completeness sake and so these important issues are not overlooked. Sometimes ‘status’ (DNR vs. full code) is added to the problem list. This can be misleading and look as though it is factoring into your care of the patient in a way you probably don’t intend. It should generally be avoided unless code status really is an active issue.

This plan section also includes pharm/non-pharm interventions, treatment, follow up, and your evidence based article

 

 

History and Physical Examination

CC: Mr. Johnson is a 53-year-old Black American male who reported to the in-patient unit after the second day of his hospitalization because “I got dizziness and felt too weak to walk.” Clinical Immunology Essay Assignment Paper

 

HPI: Mr. Johnson is a well-fed male with a considerable family history of autoimmunity and a history of Rheumatoid Arthritis for  2-month presenting after an episode of muscle weakness and dizziness. Four months ago is when Johnson started experiencing symptoms. As reported, he began to experience joint pain and fatigue in the hands and knees; hence, he was diagnosed with Rheumatoid Arthritis. At that time, he was taken through a short corticosteroid course, which got him relieved of his symptoms. Also, he was given methotrexate, which he ceased taking after two weeks because he felt it was ineffective. 

           

In the last two months, Mr. Johnson has been undergoing worsening symptoms, including headaches, dizziness, nausea, and vomiting, as well as sound and light sensitivity. No reports of convulsion, loss of consciousness, incontinence, or change of vision. The patient reports that the headaches could last for half a day once per week. The duration and frequency increased over the last month, with episodes lasting for most of the day and on a daily basis. During the episodes of headaches, the patient cannot eat. At the same time, Mr. Johnson is going through heightened joint pain in his hands and knees. The constant pain is associated with hot and swollen joints. When he tries to take  Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), the pain is not alleviated. Additionally, the patient has had a dry mouth for the last month, which caused a burning sensation in the eyes and difficulties swallowing food. Clinical Immunology Essay Assignment Paper

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Over the last month, the patient had troubled sleep. Mr. Johnson has been experiencing chills, night sweats, and fevers most of the nights. While at work three days ago, Mr. Johnson experienced a headache associated with dizziness and weakness. Since that day, the patient has had constant headaches and dizziness, as well as difficulties in eating. When he tried to eat, he could immediately vomit. No reports of changes in bowel movements, blood in urine, or stool. The joint pain has been quite severe in the last three days, rated at 10/10. After being unable to move from his bed, the patient was brought by his nurse brother to the hospital. The brother noticed a facial rash that extended over the bridge of the nose and eyelids and cervical lymphadenopathy. Mr. Johnson had no knowledge of these findings; thus, no definite time was reported about what period these findings had lasted.

 

In addition, the patient reports frustration and depressed mood associated with his inability to work when ill. For instance, the incident that occurred in the past three days caused him to leave for home due to his condition. Also, he says he has unintentionally lost weight, 36 pounds, as well as his muscle mass, decreased in the past four months. He reports experiencing clumsiness in his hands. Clinical Immunology Essay Assignment Paper

 

PMH: – In April 2019, the patient was diagnosed with Rheumatoid Arthritis.

            – Diagnosed with joint pain in the hands and knees.

            – Treated with methotrexate (took the medication for two weeks) and corticosteroids

            –  Vaccinations, such as the yearly influenza vaccine

 

PSH:  – Nasal artery cauterization and clip placement – 2012

 

Medications

            –  Ibuprofen PRN for joint pain and headaches

 

 

 

Allergies

– No reports of drug allergies

 

FHx:  – Father is 80 years old with hypertension.

            – Mother is 77 years old and living with hypothyroidism

            – Brother is 48 years old with no reported chronic health conditions

            – Daughter and son, aged  28 and 27, without known chronic health conditions

 

SHx: Mr. Johnson is a mechanical technician and a high school graduate. The patient has been married for 29 years and expresses feelings of being cared for and safe. Based on his job, which involves lifting heavy objects and climbing scaffolding and ladders. These activities are attributed to the patient’s dizziness, weakness, and joint pain. The patient reports socially drinking alcohol once to twice per month; however, he stopped since the start of his symptoms in the last four months. No information about smoking or recreational drug use. The patient is subscribed to a non-vegetarian diet. He is happily monogamous.

 

ROS: The skin is positive for facial issues in the pre-auricular area. The patient is the potential to have dizziness, fatigue, headaches, and enlarged non-tender lymph nodes. His eyes are capable of having a burning sensation. The patient has decreased appetite, anorexia, vomiting, and nausea. Mr. Johnson is positive for hot, painful, tender joints associated with subjective swelling. Psychologically, the patient has a depressed mood. Clinical Immunology Essay Assignment Paper

 

PE: Mr. Johnson is a well-nourished but ill-appearing Black American man in no acute distress.

Vitals – The patient has a temperature of 97.0, blood pressure of 126/85, heart rate of  70, and respiratory rate of 16.

Head – In the pre-auricular area, there is a macular rash.

Eyes – No signs of pallor, only a normal pink mucosa.

Neck – Anterior cervical and supraclavicular lymphadenopathy. 4-5 mm lymph nodes.

Heart – Normal heart size and non-displaced PMI.

Lungs – Lung clear to bilateral auscultation, no crackles or wheezes.

Extremities – No edema, cyanosis, or clubbing, only normal capillary refill.

Abdomen – Normoactive bowel sounds and non-distended.

Neuro – Strength of triceps, biceps, the finger spread, hand grip, knee flexion, hip flexion, and knee extension. Sensation to light touch and dull vs. sharp on distal legs and arms.

 

Diagnostic Tests

Hematologic:

• Decreased hemoglobin
• Decreased hematocrit
• Low CD4 count
• Low white blood cell (WBC) count
• Low red blood cell (RBC) count
• Elevated creatinine kinase
• Elevated lactate dehydrogenase Clinical Immunology Essay Assignment Paper

Autoimmune:

• Positive Rheumatoid Factor
• Positive anti-nuclear antibody (ANA)
• Elevated cyclic citrullinated peptide (CCP)
• Positive SS-A
• Elevated Sedimentation Rate
• Positive for Human leukocyte antigen (HLA) class 1

 

Problem List

1. Joint pain
2. Dry mouth and eye
3. Unintentional weight loss, night sweats, and fever
4. Headaches with dizziness, nausea
5. Facial rash
6. Lymphadenopathy

 

Summary Statement

In summation, Mr. Johnson is a 53-year-old African American male with a history of Rheumatoid Arthritis for two months. Also, the patient is reported to have a rich history of autoimmune disease; however, in the last four months, the patient presented with joint pain and weakness. Additionally, the patient has a two-month history of headaches with dizziness and nausea. In the last month, the patient has experienced subjective fever and night sweats, complied with symptoms of dry mouth and burning eyes, decreased hemoglobin and RBC and computed tomography (CT) with an enlarged parotid gland.

 

Assessment/Plan: Differential Diagnosis

• Most Probably: Sjogren’s Syndrome

Assessment

Mr. Johnson has a family history of autoimmune disease and a positive human leukocyte antigen genotype. Two months ago, the patient was diagnosed with Rheumatoid arthritis. The patient was present with joint pain in the hands and knees associated with a positive Rheumatoid factor, cyclic citrullinated peptide, and low CD4 count, which made this diagnosis mostly probable. Clinical Immunology Essay Assignment Paper

 

Sjogren’s syndrome is an immune system disorder characterized by two significant symptoms; a dry mouth and dry eyes (Vivino, 2017). This health condition is often paired with other disorders of the immune system, including lupus and rheumatoid arthritis. In Sjogren’s syndrome, the first impact is on the moisture-secreting and mucous membranes of the mouth and eyes, which lead to decreased saliva and tears. Carsons & Patel (2021) estimate a prevalence of 17 to 30% of the association of Rheumatoid arthritis with Sjogren’s syndrome. Thus, a strong connection exists between  Sjogren’s syndrome and the conditions identified from Mr. Johnson’s health condition.

 

According to the diagnostic tests performed on the patient, such as neck CT (showing enlarged parotid gland) and a positive SS-A, combined with the symptom of a burning eye and dry mouth, are predictive of Sjogren’s Syndrome. Vivino (2017) reports trigeminal neuralgia is a potential cause of the burning sensation, which is a neurological manifestation of this immune system disorder. However, not all manifestations identified suggest the patient has Sjogren’s syndrome. According to Baer (2018), in 20% of Sjogren’s patients, normochromic normocytic anemia can be found in them. Also, patients with an SS potentially show low counts in all cell lines, and patients reported to have cytopenia exhibit more than one cell line involvement. Thus, the form of this anemia could be an underlying cause of dizziness and muscle weakness.

 

In addition, automatic neuropathy is a potential manifestation of Sjogren’s syndrome. Automatic neuropathy is considered to occur when nerves responsible for controlling automatic body functions are damaged (Goodman, 2019). This condition is associated with dizziness, early satiety, weight loss, vomiting, and sweat abnormalities. The patient exhibits neurological manifestations of Sjogren’s syndrome through headaches with dizziness, night sweats, and GI symptoms. Also, the pre-auricular rash is associated with autoimmune diseases. Clinical Immunology Essay Assignment Paper

 

Plan

To gather substantive information, a Schirmer test will be carried out to differentiate whether the burning sensation is due to dry eyes or possibly trigeminal neuralgia. In acute care, the patient would be started on corticosteroid treatment due to chronic symptoms of Sjogren’s syndrome. Considerably, an immunosuppressant or hydrochloroquine should be administered in the long term. This approach will alleviate constitutional symptoms and joint pain. Continual monitoring of WBC and RBC will be considered to help in returning the normal ranges of their counts.

 

• Alternative: Systematic Lupus Erythematosus

Assessment

Systematic Lupus Erythematosus (SLE) can also be a possible diagnosis because an available history of autoimmune disease and positive SS-A manifests it. Leukopenia and anemia are potentially accounted for by SLE. Although, this condition will not account for dry eyes and mouth and the involvement of the parotid gland. However, the macular rash is suggestive of a malar rash. At the time of examination, it could not be ruled out that SLE was suggestive.

Plan

A continual monitoring kidney because of SS-A’s potentiality of developing Lupus Nephritis. Corticosteroids will consider for treating acute exacerbation. Clinical Immunology Essay Assignment Paper