Ms. Smith Is a 33 year old female who presents to her primary care provider for General muscle weakness and low back pain. She reports that this pain has been going on for about 3 months and the weakness has been getting worse over the last 2 weeks and she has been more fatigued with basic physical exertion. She reports getting “steroid injections” in her back previously, but they “didn’t last long at all”.
Critical Thinking Check
Bloom's Taxonomy: Application
What further history questions should be asked of Ms. Smith?
What medications does she take on a regular basis?
What has she tried in the past for her back pain? What has worked?
Is the pain associated with any specific activity or time of day? What makes it worse or makes it better?
Ms. Smith has a history of Type II Diabetes and Asthma, and has been taking inhaled corticosteroids for the past 6 years. She also reports reports having irregular menstrual cycles for the past 2 years accompanied by unexplained weight gain in her abdomen. Her previous provider told her she might have Polycystic Ovarian Syndrome.
Critical Thinking Check
Bloom's Taxonomy: Application
What initial nursing assessments should be performed?
The nurse notes purple/pink stretch marks on arms, abdomen, and thighs. Ms. Smith has multiple cuts and bruises on her arms. When asked how she got them, she says “my skin is just so thin these days”. She is obese with noticeable fatty deposits in the midsection and upper back.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What diagnostic testing do you anticipate for Ms. Smith?
Ms. Smith is sent home with a pain reliever for her back pain while the laboratory results are processed. An ultrasound of her kidneys and ovaries is ordered, pending scheduling an appointment for next week. Two days later, lab values result and show the following:
Cortisol28 mg/dL (H)
Glucose265 mg/dL
K3.3 mEq/L
Na148 mg/dL
Ca7.8 mg/dL
Testosterone levels elevated
Critical Thinking Check
Bloom's Taxonomy: Analysis
Which finding(s) is/are concerning and need to be reported to the provider? Why?
Ms. Smith likely has developed Cushing’s Syndrome due to chronic use of corticosteroids.
This causes the Adrenal Glands to over-respond, secreting excess glucocorticoids (hence the hyperglycemia and fat distribution), excess mineralocorticoids (hence the electrolyte abnormalities), and excess androgens (hence the elevated testosterone levels).
The hypocalcemia can also cause osteoporosis or soft, fragile bones
The provider notifies Ms. Smith that she needs to be seen again ASAP for further diagnostic testing to rule out any cardiac abnormalities. He tells her to stop taking her inhaled corticosteroid and prescribes a different rescue inhaler for her asthma. He also tells her she needs to begin taking some supplements, including calcium and potassium
Critical Thinking Check
Bloom's Taxonomy: Analysis
Why does Ms. Smith need to have her heart checked out? What test would they do?
The chronic use of the inhaled corticosteroids is the likely culprit – she should refer to her PCP or pulmonologist for other options to manage her asthma
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
Miriam Wahrman, MSN/Ed, RNC-MNN 
Chance Reaves, MSN-Ed, RN 