BNJ6040: Max Johnston Case Study - Nursing Assignment Help

Assignment Task

Case study 1: Max Johnston

Max Johnston, 59 years old, is Principal of an 800-pupil Secondary School and finds his job very stressful. Max is married & has 3 adult children and 4 grandchildren living in different parts of New Zealand and Australia.He has at least weekly phone contact with his children and grandchildren. He has limited time for exercise but enjoys trout fishing, playing occasional rounds of golf, and watching motor racing on TV during weekends & holidays. Max drinks approximately 18 standard drinks/week and smokes 20 cigarettes/day.

Family medical history
• Max’s father was diagnosed with hypertension, hypercholesterolaemia, Type II diabetes and died aged 63 years following a haemorrhagic stroke. 
• Max’s mother, aged 81 years currently experiences stable angina which is well controlled with GTN spray PRN. She also had glaucoma and mild osteoarthristis in both hips.
• Max’s older brother, 61 years old, was diagnosed with Type II diabetes 6 years ago. 

Past medical history
• Childhood illnesses: Measles, mumps & chickenpox + # radius & ulnar age 8 years.
• Routine life insurance health assessment age 39 years: Blood pressure 155/95, random blood glucose 9.5mmol. Advised to watch diet, exercise regularly & visit GP to monitor regularly.
• Five years ago, age 54 years, blood pressure 168/98, random blood glucose 11.7 and ruddy complexion. He reported feeling stressed and tired constantly. Further testing revealed: HbA1c 56mmol/mol, body mass index 34 (height 175cm & weight 97.5kg), total blood cholesterol 6.9 mmol/L, LDL 4.7 mmol/L, HDL 0.8 mmol/L. His GP commenced Max on Accupril 20mg BD for hypertension, Cartia 100mg mane for cardiovascular protection, Metformin 500mg BD for blood glucose control, and after an ineffective attempt to reduce serum cholesterol with a diet and exercise regime, Atorvastatin 40mg nocte.
• For 2 or 3 months Max has been unusually thirsty, is constantly feeling tired and is experiencing unexplained weight loss.
• Has reported several episodes of indigestion after meals, “tightness” across anterior chest and breathlessness on exertion unrelieved by antacids and paracetamol but mostly relieved by rest over the last 2 or 3 weeks.

Recent history
• Last night Max returned home exhausted from a business trip and went to bed early. He was awoken at 0500hrs with severe pain across his chest (pain score = 9/10), associated with breathlessness & nausea.
• Wife reported that Max’s skin was pale, almost grey, cool &profusely sweaty. On several occasions Max told her that he thought he was going to faint. She called the ambulance & it arrived within 15 minutes.

On arrival at Emergency Department 0605hrs
• Pain score 9/10 radiating into neck, left shoulder & between scapulae.
• Skin pale, cold & sweaty++. Nauseated, restless & distressed-looking
• Blood pressure 88/65, Pulse 118/min, irregular, Respiratory rate 24/min, SpO2 91% on room air, Temp 37.8 tympanic. Weak pulses palpated bilaterally.
• Chest X Ray: diffuse mild opacity bilaterally. Normal heart size & outline. Heart sounds S1S2 no added sounds.
• ECG: Sinus tachycardia. ST elevation 3mm II, III, aVF.  

Case study 2: James Ruru

James Ruruis a 68 year old man diagnosed with prostate cancer 8 years ago. At that time he underwent prostatectomy and radiotherapy which left him with urinary incontinence controlled with continence products. His regular follow ups and PSA assessments revealed that he developed metastatic disease 2 years ago. Metastatic tumours where located in his lung and right 4th rib (posterior). James refused orchidectomy and hormone therapy and subsequently had 3 courses of immunotherapy. Has been instigated but at this time is considered palliative rather than curative. He is married with 3 adult children and 4 grandchildren living locally. He enjoys being with family and fishing. He is an ex-smoker with a 50 pack year history. He stopped smoking when originally diagnosed with prostate cancer.

Family History
• Father died of a CVA aged 59
• Mother is still alive and in Rest home care
• His brother and sister are both in good health

Past Medical History
• Childhood illnesses : measles, mumps and chicken pox
• # radius 15 years (rugby injury)
• MVA 35 years #ribs
• Gout diagnosed at 50 years treated with daily allopurinol 100 mg under good control.
• After treatment for metastases and after discussion James was referred to Hospice care with the understanding that his condition was palliative. Under shared GP and Hospice care for the last 3 months.
Recent History
James visited his GP yesterday complaining of severe chest and back pain uncontrolled with previously prescribed paracetomol and Voltaren. Also ongoing nausea and vomiting. Still able to eat and drink though questionable as to whether he is absorbing his oral medications. On review of his blood tests the GP noted significant electrolyte abnormalities and after d/w the Hospice physician it was decided to admit James to Hospice for symptom management.

On presentation to Hospice:
• James arrived at Hospice accompanied by his wife and son all expressed anxiety about his situation and where concerned that he may not be able to leave Hospice.
• Pain to lower back and thorax 8/10 , constant, non-radiating, somatic in nature.
• B/P 155/90, SaO2 95%, P = 85 and regular, T 36.7, RR 20 BPM.
• Ongoing nausea. Vomiting 2-3 times per day – stomach contents. Not clinically dehydrated.
• Chest x-ray shows a # R) 4th rib. Plus a second area of density on his 6th rib.

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