Tumor case study

NOTE

S: 16-year-old Hispanic male with weakness and reported loss of consciousness on Sunday for approximately 2–3 minutes. The episode was unwitnessed by providers but observed by his mother. He regained awareness quickly and was oriented. No EMS called or ER evaluation performed. Patient has a history of brain tumor with surgeries in 2016 and 2020; receives monthly chemotherapy. Complaints of fatigue, shortness of breath on exertion, poor appetite, difficulty walking, and generalized weakness. Often sleeps during the day and struggles to expectorate sputum. Uses a walker or cane for ambulation. Mother confirms poor appetite and notes he has not been eating well. Last labs (2/6/25) were WNL. No vomiting or GI symptoms. Neurology consult is scheduled in 2 weeks. Past Medical History: Brain tumor with surgeries (2016, 2020), on chemotherapy Social History: Lives with mother, no current school attendance due to medical condition

O: VS: Temp: 98.6°F | HR: not taken | RR: not taken | BP: not taken | Wt: 147.6 lbs (66.95 kg) | Ht: 60 in (152.4 cm) | BMI: 28.82 (95.98%) General: Alert, well-nourished, no acute distress Head: Normocephalic, atraumatic. Eyes: PERRLA, sclera anicteric. ENT: Moist mucosa, clear throat. Neck: Supple, full ROM, no LAD. Skin: Warm, dry, no rashes Heart: RRR, no murmurs, normal S1/S2. Lungs: Clear to auscultation, good air movement Abdomen: Soft, nontender, no organomegaly. Extremities: No edema, no cyanosis or clubbing Neuro: Alert, oriented x3, generalized weakness with ambulation, uses walker; no focal deficits

A: R53.1 – Weakness. R63.0 – Anorexia. Z85.841 – Personal history of brain tumor. Z51.11 – Encounter for antineoplastic chemotherapy

P: Weakness: Safety reinforced, use of walker/cane encouraged, continue neurology referral

Anorexia: Counsel on iron-rich and calorie-dense foods: lean meats, fortified cereals, beans, greens. Vitamin B12, folate, and Vitamin C-rich foods recommended. Encourage small, frequent meals and high-calorie shakes. Monitor for weight loss and hydration status. Energy conservation techniques recommended. Moderate exercise with clearance from oncologist

Education: Emphasized nutrition, hydration, and rest. Encouraged mother to monitor for any new neurologic symptoms, prolonged fatigue, vomiting, or worsening weakness. Instructed to go to ER for any acute changes in consciousness, severe fatigue, vomiting, seizures, or breathing issues. Regular follow-up with oncology, neurology, and PCP encouraged. Follow-Up: Neurology in 2 weeks. RTC in 3 months or sooner if symptoms worsen

This is just a sample; don’t use these medications. NOTE: Pharmacology interventions MUST BE IN THIS FORMAT

Ciprofloxacin (Cipro) 500 mg tablet orally every 12hrs for seven days

Acetaminophen 650 mg tablet orally every 4-6 hours as needed.

Ondansetron (Zofran) 8 mg tablet orally every 12 hours as needed for seven days.

APA FORMAT, AND REFERENCES, peer review scholarly resource cited in APA format from 2020-2025 only. (Within the last five years)

Please do not solely use a website as your scholarly reference. It is fine to use it as a supplement, but a journal article or text should be referenced.

Please use North American peer-reviewed journals ONLY.

DO NOT use any European Journal

NUR 638 CLINCIAL CASE STUDY (CCS)-GRADING RUBRIC

	Point Breakdown	Points Earned
History (25 points total)
Chief Complaint	2
History of Present Illness	6
History: past medical hx, prenatal, medications, allergies, surgeries, vaccines	6
Developmental History	4
Family History, Social History	2
Review Of Systems	5
Physical Exam (25 points total)
Appropriate Systems Examined (Include VS, growth percentiles)	8
Appropriate exam technique to evaluate problem	5
Age-appropriate developmental exam	6
Accuracy of documentation, appropriate terminology	6
Assessment: Differential Diagnoses (DD) (25 points total)
Three DD, primary DD listed first	9 (3 @ 3points each)
Pathophysiology support primary DD	4
Definition for each DD	9 (3 @ 3 points each)
Rationale and pertinent positives/negatives for each DD	3
Plan of Care (25 points total)
Testing and diagnostic studies	2
Pharmacologic (including prescription, OTC, herbals) ALL in prescriptive format Include dosing calculation parameters for each medication (ex., mg/kg divided bid)	6
Non-Pharmacologic Treatment/Symptomatic Treatment	4
Patient Education	4
Anticipatory Guidance	5
Follow-up (includes symptoms to watch for, when to call office, when to return)	4
Deductions:
Grammar, Spelling Errors: -1 point each error
Incorrect APA Format: -5 points
Incorrect References: -2 points each incorrect or missing references
Total Points