1 A 45-year-old male comes to the clinic with a chief complaintQUESTION 1 A 45-year-old male comes to the clinic with a chief complaint of epigastric abdominal pain that has persisted for 2 weeks. He describes the pain as burning, non-radiating and is worse after meals. Also, he denies nausea, vomiting, weight loss or obvious bleeding. Finally, he admits to bloating and frequent belching.PMH-+ for osteoarthritis, seasonal allergies with frequent sinusitis infections.Meds-Zyrtec 10 mg po daily and takes it year-round, ibuprofen 400-600 mg po prn painFamily Hx-non contributarySocial history-recently divorced and expressed concern at how expensive it is to support 2 homes. Works as a manager at a local tire and auto company. He has 25 pack/year history of smoking, drinks 2-3 beers/day, and drinks 5-6 cups of coffee per day. He denies illicit drug use, vaping or unprotected sexual encounters.Breath test in the office revealed + urease.The healthcare provider suspects the client has peptic ulcer disease.1 of 2 Questions:What factors may have contributed to the development of PUD?2 of 2 Questions:How do these factors contribute to the formation of peptic ulcers?QUESTION 3 A 36-year-old morbidly obese female comes to the office with a chief complaint of “burning in my chest and a funny taste in my mouth”. The symptoms have been present for years but patient states she had been treating the symptoms with antacid tablets which helped until the last 4 or 5 weeks. She never saw a healthcare provider for that. She says the symptoms get worse at night when she is lying down and has had to sleep with 2 pillows. Says she has started coughing at night which has been interfering with her sleep. Also, denies palpitations, shortness of breath, or nausea.PMH-HTN, venous stasis ulcers, irritable bowel syndrome, osteoarthritis of knees, morbid obesity (BMI 48 kg/m2)Family history-non contributaryMedications-amlodipine 10 mg po qd, dicyclomine 20 mg po, ibuprofen 600 mg po q 6 hr prnSocial hx- 15 pack/year history of smoking, occasional alcohol use, denies vapingThe health care provider diagnoses the patient with gastroesophageal reflux disease (GERD).Question:The client asks the APRN what causes GERD. What is the APRN’s best response?QUESTION 4 A 34-year-old construction worker presents to his Primary Care Provider (PCP) with a chief complaint of passing foul smelling dark, tarry stools. He stated the first episode occurred last week, but it was only a small amount after he had eaten a dinner of beets and beef. The episode today was accompanied by nausea, sweating, and weakness. He states he has had some mid epigastric pain for several weeks and has been taking OTC antacids. The most likely diagnosis is upper GI bleed which won’t be confirmed until further endoscopic procedures are performed.Question:What factors can contribute to an upper GI bleed?Question 5 A 64-year-old steel worker presents to his Primary Care Provider (PCP) with a chief complaint of passing bright red blood when he had a bowel movement that morning. He stated the first episode occurred last week, but it was only a small amount after he had eaten a dinner of beets and beef. The episode today was accompanied by nausea, sweating, and weakness. He states he has had some left lower quadrant pain for several weeks but described it as “coming and going”. He says he has had a fever and abdominal cramps that have worsened this morning. The likely diagnosis is lower GI bleed secondary to diverticulitis.Question:What can cause diverticulitis in the lower GI tract?QUESTION 6 A 48-year-old man presents to his gastroenterologist for increasing abdominal girth and increasing jaundice. He has a long history of alcoholic cirrhosis and has multiple admissions for encephalopathy and GI bleeding from esophageal varices. He has been diagnosed with portal hypertension and tells the APRN that he was told he had chronic, non-curable cirrhosis.Question:How does cirrhosis cause portal hypertension?QUESTION 7 A 48-year-old man presents to his gastroenterologist for increasing abdominal girth and increasing jaundice. He has a long history of alcoholic cirrhosis and has multiple admissions for encephalopathy and GI bleeding from esophageal varices. He has been diagnosed with portal hypertension. The increased abdominal girth has been progressive, and he says it is getting hard to breathe. The APRN reviews his last laboratory data and notes that the total protein is 4.6 gm/dl and the albumin is 2.9 g/dl. Upon exam, he has icteric sclera, jaundice, and abdominal spider angiomas. There is a significant fluid wave when percussed. The APRN tells the patient that he has ascites.Question:Discuss how ascites develops as a result of portal hypertension.QUESTION 8 A 45-year-old man with known alcoholic cirrhosis, portal hypertension, and ascites is brought to the ED by his family due to increasing confusion. The family states that he had been stumbling for several days but had not fallen. The family also noted that he had been “flapping his hands” as well. Labs in the ED reveal Hgb 9.4 g/dl, Hct 28.0 %, ammonia (NH3) level is 159 μmol/L. The APRN informs the family that the patient has developed hepatic encephalopathy (HE).Question:Explain how hepatic encephalopathy develops in patients with cirrhosis of the liver.QUESTION 9 A 65-year-old man with a history of atrial fibrillation presents to his PCP’s office 2 months after suffering from a myocardial infarction. He declined anticoagulation due to fear he would bleed to death. Has had sudden-onset, moderately severe diffuse abdominal pain that began 18 . Has been vomiting, and he has had several episodes of diarrhea, the last of which was bloody. He has a fever of 100.9 ˚ F. CBC reveals WBC of 15,000/mm3.Question:What is the most likely mechanism behind his current symptoms?QUESTION 10 A 46-year-old Caucasian female presents to the PCP’s office with a chief complaint of severe, intermittent right upper quadrant pain for the last 3 days. The pain is described as sharp and has occurred after eating french fries and cheeseburgers and radiates to her right shoulder. She has had a few episodes of vomiting “green stuff”. States had fever and chills last night which precipitated her trip to the office. She also had some dark orange urine, but she thought she was dehydrated.Physical exam: slightly obese female with icteric sclera as well as generalized jaundice. Temp 101˚F, pulse 108, respirations 18. Abdominal exam revealed rounded abdomen with slightly hypoactive bowel sounds. + rebound tenderness on palpation of right upper quadrant. No tenderness or rebound in epigastrium or other quadrants. Labs demonstrate elevated WBC, elevated serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. Serum bilirubin (indirect) 2.5 mg/dl. Abdominal ultrasound demonstrated enlarged gall bladder, dilated common bile duct and multiple stones in the bile duct. The APRN diagnoses the patient with acute cholecystitis and refers her to the ED for further treatment.Question 1 of 2:Describe how gallstones are formed and why they caused the symptoms that the patient presented with.QUESTION 11 A 46-year-old Caucasian female presents to the PCP’s office with a chief complaint of severe, intermittent right upper quadrant pain for the last 3 days. The pain is described as sharp and has occurred after eating french fries and cheeseburgers and radiates to her right shoulder. She has had a few episodes of vomiting “green stuff”. States had fever and chills last night which precipitated her trip to the office. She also had some dark orange urine, but she thought she was dehydrated.Physical exam: slightly obese female with icteric sclera as well as generalized jaundice. Temp 101˚F, pulse 108, respirations 18. Abdominal exam revealed rounded abdomen with slightly hypoactive bowel sounds. + rebound tenderness on palpation of right upper quadrant. No tenderness or rebound in epigastrium or other quadrants. Labs demonstrate elevated WBC, elevated serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. Serum bilirubin (indirect) 2.5 mg/dl. Abdominal ultrasound demonstrated enlarged gall bladder, dilated common bile duct and multiple stones in the bile duct. The APRN diagnoses the patient with acute cholecystitis and refers her to the ED for further treatment.Question 2 of 2:Explain how the patient became jaundiced.QUESTION 12 Ruth is a 49-year-old office worker who presents to the clinic with a chief complaint of abdominal pain x 2 days. The pain has significantly increased over the past 6 hours and is now accompanied by nausea and vomiting. The pain is described as “sharp and boring” in mid epigastrum and radiates to the back. Ruth admits to a long history of alcohol use, and often drinks up to a fifth of vodka every day.Physical Exam:Temp 102.2F, BP 90/60, respirations 22. Pulse Oximetry 92% on room air.General: thin, pale white female in obvious pain and leaning forward. Moving around on exam table and unable to sit quietly.CV-tachycardic. RRR without gallops, rubs, clicks or murmursResp-decreased breath sounds in both bases with poor inspiratory effortAbd- epigastric guarding with tenderness. No rebound tenderness. Negative Cullen’s and + Turner’s signs observed. Hypoactive bowel sounds x 2 upper quadrants, and no bowel sounds heard in both lower quadrants.The APRN makes a tentative diagnosis of acute pancreatitis based on history and physical exam and has the patient transferred to the ER where laboratory and radiographic exams reveal acute pancreatitis.Question:Explain how pancreatitis develops and the role alcohol played in this patient’s case.QUESTION 13 A 23-year-old bisexual man with a history of intravenous drug abuse presents to the clinic with a chief complaint of fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, and dark urine. He says the symptoms started about a month ago and have gotten steadily worse. He admits to reusing needles and had unprotected sexual relations with a man “a couple months ago”.PMH-noncontributory.Social/family history-works occasionally as a night clerk in a hotel. Parents without illnesses. Admits to bisexual sexual relations and intravenous heroin use. He has refused drug rehabilitation. 3 year/pack history of tobacco but denies vaping.Physical exam unremarkable except for palpable liver edge 2 fingerbreadths below costal margin. No ascites or jaundice appreciated.The APRN suspects the patient has Hepatitis B given the strong history of risk factors. She orders a hepatitis panel which was positive for acute Hepatitis B.Question:What are the important hepatitis markers that indicated the patient had acute hepatitis B?QUESTION 14 Hannah is a 19-year-old college sophomore who came to Student Health with a chief complaint of lower abdominal pain. She says the pain has been present for 2 months and she has had multiple episodes of diarrhea alternating with constipation, and anorexia. She says she has lost about 10 pounds in these 2 months without dieting. The abdominal pain has gotten worse in the last 2 hours, but she thought she had “the GI bug” like other students at her Synagogue had.Physical exam-noncontributory except for the abdomen which was lightly distended with no visible masses. Normoactive BS x 4. Diffuse tenderness throughout but increased pain on deep palpation LUQ & LLQ. Slight guarding but no rebound tenderness or rigidity.Rectal-tight anal sphincter and patient grimacing in pain during exam. Slightly + guaiac stool.Based on her history and current symptoms, the APN arranges for a consult with a gastroenterologist who diagnoses Hannah with ulcerative colitis (UC).Question:How does ulcerative colitis develop in a susceptible person?QUESTION 15 A 64-year-old woman with long standing coronary artery disease presents to the clinic with lower extremity swelling, abdominal distension, and shortness of breath. Patient states she has a 30-pound weight gain in 6 weeks and is now requiring 3 pillows to sleep.On physical exam the patient is a well-developed, well-nourished female exhibiting signs of respiratory distress with use of accessory muscles. Blood pressure 150/80, pulse 105, respirations 28 and labored. Body weight 89 kg. HEENT was unremarkable. Cardiac exam had an S1, S2 and S3 without S4 or murmur. Respiratory exam was positive for bilateral rales 1/2 up both lung fields. Abdomen was enlarged with a positive fluid wave. Lower extremities were remarkable for 3+ pitting edema.Laboratory data was significant for an increase in K+ from 3.4 mmol/l to 6.1 mmol/l in 2 weeks, BUN increased from 18 mg/dl to 104 mg/dl, and creatinine increased from 0.8 mg/dl to 6.9 mg/dl.CXR revealed congestive heart failure. The APRN calls the cardiologist on call who admits the patient to the hospital and orders a nephrology consult.She was diagnosed with exacerbation of congestive heart failure (CHF) and acute kidney injury (AKI).Question:What type of acute kidney injury does the patient have and what factors contributed to this diagnosis?QUESTION 16 The APRN is giving a pathophysiology lecture to APRN students on renal blood flow, related hormones, and glomerular filtration rate.Question: What would be the most important concept of glomerular filtration rate that the APRN should address?QUESTION 17 The APRN is giving a pathophysiology lecture to APRN students on renal blood flow, glomerular filtration rate, autoregulation, and related hormone factors regulating renal blood flowQuestion:What would be the most important concept of autoregulation that the APRN should address?QUESTION 18 The APRN is giving a pathophysiology lecture to APRN students on renal blood flow, glomerular filtration rate, autoregulation, and also related hormone factors regulating renal blood flowQuestion:What would be the most important concept of hormonal regulation that the APRN should address?QUESTION 19 A 28-year-old female comes to the clinic with a chief complaint of right flank pain, urinary frequency, and foul-smelling urine. The symptoms have been present for 3 days but this morning, the patient states she had a fever of 101 F and thought she should get it checked out. Physical exam noncontributory with the exception of right costovertebral angle (CVA) tenderness upon percussion. Urine dipstick shows + blood, + bacteria and + white blood cells. Renal ultrasound reveals right staghorn renal calculus and the patient was diagnosed with acute pyelonephritis.Question:How does a renal calculi calculus contribute to acute pyelonephritis?QUESTION 20 Mr. Kent is a 45-year-old African American male with a history of Type 2 diabetes, hypertension, and hyperlipidemia. His renal function has slowly decreased over the past 4 years and his nephrologist has told him that his GFR has decreased to 15cc ml/min and will soon need renal dialysis for chronic renal failure.Question:How does chronic renal failure develop?
