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Case Study 7-1: Comprehensive History and Physical

C.F., a 46-year-old married Asian woman, works as an office manager for an insurance company. This morning, she had a follow-up visit with her oncologist and was sent to the hospital for immediate admission for possible recurrence or sequelae of her ovarian cancer. She is alert, articulate, and a reliable reporter.

CC: C.F. presents with mild, low, aching pelvic pain and low abdominal fullness. She states, "I feel like I have cramps and am bloated. I've even gained 6 pounds. Sometimes I'm so tired I cannot do my work without a short nap."

HPI: C.F. has been in remission for 14 months from aggressively treated ovarian carcinoma. She presents with mild abdominal distention and tenderness on deep palpation of the lower pelvis. C.F. claims a feeling of fullness in the lower abdomen, loss of appetite, and inability to sleep through the night. She is afraid that her cancer was not cured. Sometimes her heart races and she cannot catch her breath, but with two children in college, she cannot afford to miss work.

MEDS: Therapeutic vitamin X 1/day. Valium 5 mg every 6 hours (q6h) as needed (prn) for anxiety. Benadryl 25 mg at bedtime (hs) prn for insomnia. Echinacea tea 3 cups per day to prevent colds or flu. Ginkgo biloba 3 caps/day for energy.

ALLERGIES: NKDA; no food allergies

PMH: C.F. was diagnosed with ovarian CA 4 years ago and treated with surgery, radiation, and chemotherapy. A total abdominal hysterectomy (removal of the uterus) with bilateral removal of the oviducts and ovaries was performed. At the time of surgery, the pelvic lymph nodes tested negative for disease. Chemotherapy and radiation therapy occurred after surgical recovery. C.F. has been well and capable of full ADL until 4 weeks ago. Childhood history is unremarkable, with normal childhood diseases, including measles, mumps, and chicken pox. C.F. was born and raised in this country. She has no other adult diseases, surgery, or injuries.

CURRENT HEALTH Hx: Denies tobacco, ETOH, or recreational drugs or substances. She exercises 3 to 5 times per week with aerobic exercise class and treadmill. She is a vegetarian and drinks 1 to 5 cups of green tea per day. Immunizations are up to date; unsure of last tetanus booster. Recent negative mammogram and negative TB test (PPD).

FAMILY Hx: Both parents alive and well. Maternal aunt died of "stomach tumor" at age 37. TPR & BP & PAIN: 37C-96-22 126/72 in no acute distress

HEENT: WNL. Normocephalic, fundi benign, PERRLA, uncorrected 20/20 vision, mouth clear, good dental health, neck supple w/o rigidity, thyromegaly, or cervical lymphadenopathy; trachea midline. No carotid bruits (sounds). LUNGS: All lobes clear to auscultation and percussion HEART: Rate 96 bpm, regular; no murmurs, gallops, or rubs BREASTS: Symmetrical, w/o masses or discharge

ABDOMEN: Skin intact with healed suprapubic midline surgical incision and a symmetrical area of discoloration and dermal thickness from radiation therapy. Bowel sounds active and normal. Suprapubic tenderness on palpation. No hepatosplenomegaly. Absence of inguinal lymph nodes on palpation. Kidneys palpable. Rectal exam WNL. Hemoccult test (stool test for blood) result negative. GU: Unremarkable. Surgical menopause.

MUSCULOSKELETAL: WNL. No weakness, limitation of mobility, joint pain, stiffness, or edema. NEUROLOGIC: All reflexes intact. No syncope, paralysis, numbness. DIAGNOSTIC IMPRESSION: Possible recurrence of ovarian CA, ascites

TREATMENT PLAN: Send blood for CA-125 (genetic marker for ovarian cancer). Schedule abdominal paracentesis and second-look diagnostic laparoscopy with biopsy and tissue staging. D/C all herbal supplements.

Case Study 7-2: Diagnostic Laparoscopy

For a laparoscopy, C.F. was given general anesthesia and her trachea was intubated. She was placed in lithotomy position with arms abducted. Her abdomen was insufflated with carbon dioxide (CO2) through a thin needle placed below the umbilicus. Three trocar punctures were made to insert the telescope with camera and the cutting and grasping instruments. Biopsies were taken of several pelvic lymph nodes and sent to the pathology laboratory. There were many adhesions from prior surgery, which were lysed to mobilize her organs and enhance visualization. A loop of small bowel, which had adhered to the anterior abdominal wall, had been punctured when the trocar was introduced. The surgeon repaired the defect with an endoscopic stapler and irrigated the abdomen with 3 L of NSS mixed with antibiotic solution.

Case Study 7-3: Postoperative Care

After surgery, C.F. complained of numbness, tingling, and paralysis in her right arm and bilateral sub-scapular pain when she stood. The retained CO2 was eventually absorbed, and the subscapular pain diminished. A consult with a neurologist confirmed that she sustained a nerve injury during surgery from hyperabduction of the arm.

Biopsy results were negative, there was no fluid found on paracentesis, and the CA-125 was below 35U/mL, which is negative for recurrence. She was referred to physical therapy to strengthen and maintain range of motion (ROM) in her arm. Occupational therapy was scheduled to help her gain independence with ADL, along with psychological counseling to help her verbalize her fears and gain a sense of control.


Write the word from the case study that completes each of the following statements:

1. Secondary conditions, complications, or lasting effects of C.F.'s cancer would be called

2. Examination by touching the surface of the body is _.

3. The size and shape of C.F.'s head was described as _.

4. A collection of abdominal fluid (ascites) would be drained by a cavity puncture and drainage procedure called a(n) _.

5. Removal of tissue for microscopic examination is _.

6. A surgical procedure in which an endoscope is inserted through the abdominal wall to visualize the abdominal cavity and determine the cause of a disorder is a(n)

7. Extreme or overextension of an arm or leg away from the midline of the body is

Multiple choice: Select the best answer and write the letter of your choice to the left of each number.

_ 8. C.F.'s cancer was in a state of apparent cure with no active signs of disease. This state is called _.

a. exacerbation b. syndrome c. remission d. sequelae e. tumor staging

_ 9. C.F. claimed that her heart races and she cannot catch her breath. The terms for these conditions are _ and _.

a. tachypnea and dyspnea b. tachycardia and dyspnea c. dyspnea and tachycardia d. tachycardia and bradypnea e. bradycardia and tachypulmono

_ 10. Hepatosplenomegaly means:

a. removal of the liver and spleen b. prolapse of the heart and spleen c. hemorrhage of the liver and spleen d. enlargement of the liver and spleen e. surgical repair of the kidney and liver

_ 11. C.F.'s abdominal cavity and organs were bound with fibrous tissue bands, which had to be lysed during surgery. These bands are called _.

a. prodromes b. sequelae c. adhesions d. ascites e. fibroids

_ 12. The incidental (accidental) puncture of the intestines and nerve injury to C.F.'s arm are not expected outcomes of surgery. They are critical incidents and occurred despite attempts to protect her from harm. The term for this type of disorder is__

a. iatrogenic b. nosocomial c. idiopathic d. etiologic e. surgical misadventure

Give the meaning of each of the following abbreviations:














20. NSS


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Eliminating Stress and Anxiety From Your Life

Eliminating Stress and Anxiety From Your Life

It seems like you hear it all the time from nearly every one you know I'm SO stressed out!? Pressures abound in this world today. Those pressures cause stress and anxiety, and often we are ill-equipped to deal with those stressors that trigger anxiety and other feelings that can make us sick. Literally, sick.

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