Discussion
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Discussion4ADVHEALTHASSESSMENT.docx
Discussion6ADVHealthassessment.docx
Discussion3ADVhealthassessment.docx
Discussion7AdvHealthAssessment.docx
Discussion4ADVHEALTHASSESSMENT.docx
Module 4 Discussion
Class: Nur 504 Advanced Health Assessment
Throat, Respiratory & Cardiovascular Disorders
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.
Your case number is # 2
|
|
Case 2 |
|
Chief Complaint (CC) |
A 25-year-old Hispanic female, computer programmer presents to your clinic complaining of a 12-day history of a runny nose |
|
Subjective |
States that her symptoms began about 12 days ago. She suffers from allergies; she gets a runny nose during the springtime, pollen season. However, in the winter, her allergies are not a problem. |
|
Objective Data |
|
|
VS |
(BP) 115/75, (P) 89, (RR) 16, (T) 100.4°F (38°C), O2 sat 98% on room air |
|
General |
No signs of acute distress. Patient appears mildly fatigued. She is breathing through her mouth. Breathing easily. Voice has a nasal quality to it. |
|
HEENT |
Ear canals: normal; EYES: normal; NOSE: Bilateral erythema and edema of turbinates with significant yellow drainage on the right. Nares: Obstructed air passages |
|
Respiratory |
CTA AP&L |
|
Neck/Throat |
Posterior pharynx: mildly injected, scant postnasal drainage (PND), no exudate, tonsils 1+, no cobblestoning |
|
Heart |
Regular rate and rhythm, no murmur, S3, or S4 |
Based on case # 2, answer the following questions:
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms.
5. Give rationales for each differential diagnosis.
Discussion6ADVHealthassessment.docx
Module 6 Discussion
Class: Nur 504 Advanced Health Assessment
Neurological & Male Genitourinary Disorders
For this Discussion, you will take on the role of a clinician who is building a health history for case # 2
|
|
Case 2 |
|
Chief Complaint (CC) |
“I had a severe headache yesterday with difficulty to speak” |
|
History of Present Illness (HPI) |
A 64-year-old African American female who reports having a severe pulsatile diffuse headache yesterday with sudden difficulty to talk with last for about two hours. She did not seek medical attention. This morning she woke up with no problems but is here today due her husband advise. |
|
PMH |
Atrial Fibrillation, Hypertension. Is allergic to Non-steroidal Anti-inflammatory drugs Aspirin |
|
Drug Hx |
Losartan 50 mg Xarelto 15 mg BID |
|
Subjective |
Feels Palpitations, joint pain with yesterday’s episode |
|
Objective Data |
|
|
VS |
B/P 131/80; temperature 98.2°F; (RR) 18; (HR) 84, irregular; oxygen saturation (PO2) 96%; |
|
General |
well-developed female, no acute distress |
|
HEENT |
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. |
|
Lungs |
CTA AP&L |
|
Card |
Irregular heart beat with normal rate |
|
Abd |
No tenderness normoactive bowel sounds x 4; |
|
Rectal exam |
Non contributory |
|
Integument |
intact without lesions masses or rashes. |
|
Neuro |
No obvious deficits and CN grossly intact II-XII |
Based on case number 2, answer the following questions:
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms.
5. Give rationales for each differential diagnosis.
6. What teachings will you provide?
7. Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.
Discussion3ADVhealthassessment.docx
Discussion Module 3- Skin, Eye, & Ear Disorders
Class: Nur 504 Advanced Health Assessment.
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your case number is # 2.
|
|
Case 1 |
Case 2 |
Case 3 |
|
Chief Complaint (CC) |
A 57-year-old man presents to the office with a complaint of left ear drainage since this morning. |
A 45-year-old female presents with a complaint of an itchy red rash on her arms and legs for about two weeks. |
A 11-year-old female patient complains of red left eye and edematous eyelids. Her mother states the child complains of “sand in my left eye.” |
|
Subjective |
Patient stated he was having pulsating pain on left ear for about 3 days. After the ear drainage the pain has gotten a little better. |
She has been going on a daily basis to the local YMCA with children for Summer camp. |
Patient noticed redness three days ago. Denies having any allergies. Symptoms have gotten worse since she noticed having the problem. |
|
Objective Data |
|||
|
VS |
(T) 99.8°F; (RR) 14; (HR) 72; (BP) 138/90 |
(T) 98.3°F; (RR) 18; (HR) 70, regular; (BP) 118/74 |
(T) 98.2°F; (RR) 18; (HR) 78; BP 128/82; SpO2 96% room air; weight 110 lb. |
|
General |
well-developed, healthy male |
healthy-appearing female in no acute distress |
well-developed, healthy, 11 years old |
|
HEENT |
EAR: (R) external ear normal, canal without erythema or exudate, little bit of cerumen noted, TM- pearly grey, intact with light reflex and bony landmarks present; (L) external ear normal, canal with white exudate and crusting, no visualization of tympanic membrane or bony landmarks, no light reflex EYE: bilateral anicteric conjunctiva, (PERRLA), EOM intact. NOSE: nares are patent with no tissue edema. THROAT: no lesions noted, oropharynx moderately erythematous with no postnasal drip. |
EYES: no injection, no increase in lacrimation or purulent drainage; EARS: normal TM: Normal |
EYES: very red sclera with dried, crusty exudates; unable to open eyes in the morning with the left being worse than the right |
|
Skin |
No rashes |
CTA AP&L |
CTA AP&L |
|
Neck/Throat |
no neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged; trachea midline |
mild edema with inflammation located on forearms, upper arms, and chest wall, thighs and knees; primary lesions are a macular papular rash with secondary linear excoriations on forearms and legs |
|
Based on case number # 2, answer the following questions:
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms.
5. Give rationales for your each differential diagnosis.
· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.
Discussion7AdvHealthAssessment.docx
Module 7 Discussion
Class: Nur 504 Advanced Health Assessment
Female Genitourinary, & Musculoskeletal
For this Discussion, you will take on the role of a clinician who is building a health history for case # 2
|
|
Case 2 |
|
Chief Complaint (CC) |
“I have pain during intercourse and urination” |
|
History of Present Illness (HPI) |
A 19-year-old female reports to you that she has “sores” on and in her vagina for the last three months. |
|
Drug Hx |
She tries to practice safe sex but has a steady boyfriend and figures she doesn’t need to be so careful since she is on the birth control pill |
|
Family Hx |
|
|
Subjective |
states “I have sores and bumps on the inner creases of my thighs and pelvic area”. “There is yellowish discharge from the sores that comes and goes” |
|
Objective Data |
|
|
VS |
temperature: 100.2°F; pulse 92; respirations 18; BP 122/78; weight 156 lbs, 25 lbs overweight; height 5′3″ |
|
General |
patient appears to have good hygiene; minimal makeup, pierced ears, no tattoos; well nourished (slightly overweight); no obvious distress noted |
|
HEENT |
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip. |
|
Lungs |
within normal limits, appropriate lung sounds auscultated, clear and equal bilaterally |
|
Card |
S1S2 without rub or gallop |
|
Breast |
• INSPECTION: no dimpling or abnormalities noted upon inspection • PALPATION: Left breast no abnormalities noted. Right breast: denies tenderness, pain, no abnormalities noted. |
|
Lymph |
Inguinal Lymph nodes: tenderness bilaterally, numerous, 1 cm in size |
|
Abd |
tender during palpation; the left lower quadrant was very tender during palpation; patient denies nausea or vomiting |
|
GU |
labia major and minor: numerous ulcerations, too many to count; some ulcerations enter the vaginal introitus; no ulcerations in the vagina mucosa; cervix is clear, some greenish discharge; bimanual exam reveals tenderness in left lower quadrant; able to palpate the left ovary; unable to palpate the right ovary; no tenderness; uterus is normal in size, slight tenderness with cervical mobility |
|
Integument |
|
|
MS |
Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation. |
|
Neuro |
No obvious deficits and CN grossly intact II-XII |
Once you received your case number, answer the following questions:
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms.
5. Give rationales for each differential diagnosis.
6. What teachings will you provide?
· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.
Discussion4ADVHEALTHASSESSMENT.docx
Module 4 Discussion
Class: Nur 504 Advanced Health Assessment
Throat, Respiratory & Cardiovascular Disorders
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.
Your case number is # 2
|
|
Case 2 |
|
Chief Complaint (CC) |
A 25-year-old Hispanic female, computer programmer presents to your clinic complaining of a 12-day history of a runny nose |
|
Subjective |
States that her symptoms began about 12 days ago. She suffers from allergies; she gets a runny nose during the springtime, pollen season. However, in the winter, her allergies are not a problem. |
|
Objective Data |
|
|
VS |
(BP) 115/75, (P) 89, (RR) 16, (T) 100.4°F (38°C), O2 sat 98% on room air |
|
General |
No signs of acute distress. Patient appears mildly fatigued. She is breathing through her mouth. Breathing easily. Voice has a nasal quality to it. |
|
HEENT |
Ear canals: normal; EYES: normal; NOSE: Bilateral erythema and edema of turbinates with significant yellow drainage on the right. Nares: Obstructed air passages |
|
Respiratory |
CTA AP&L |
|
Neck/Throat |
Posterior pharynx: mildly injected, scant postnasal drainage (PND), no exudate, tonsils 1+, no cobblestoning |
|
Heart |
Regular rate and rhythm, no murmur, S3, or S4 |
Based on case # 2, answer the following questions:
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms.
5. Give rationales for each differential diagnosis.
Discussion6ADVHealthassessment.docx
Module 6 Discussion
Class: Nur 504 Advanced Health Assessment
Neurological & Male Genitourinary Disorders
For this Discussion, you will take on the role of a clinician who is building a health history for case # 2
|
|
Case 2 |
|
Chief Complaint (CC) |
“I had a severe headache yesterday with difficulty to speak” |
|
History of Present Illness (HPI) |
A 64-year-old African American female who reports having a severe pulsatile diffuse headache yesterday with sudden difficulty to talk with last for about two hours. She did not seek medical attention. This morning she woke up with no problems but is here today due her husband advise. |
|
PMH |
Atrial Fibrillation, Hypertension. Is allergic to Non-steroidal Anti-inflammatory drugs Aspirin |
|
Drug Hx |
Losartan 50 mg Xarelto 15 mg BID |
|
Subjective |
Feels Palpitations, joint pain with yesterday’s episode |
|
Objective Data |
|
|
VS |
B/P 131/80; temperature 98.2°F; (RR) 18; (HR) 84, irregular; oxygen saturation (PO2) 96%; |
|
General |
well-developed female, no acute distress |
|
HEENT |
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. |
|
Lungs |
CTA AP&L |
|
Card |
Irregular heart beat with normal rate |
|
Abd |
No tenderness normoactive bowel sounds x 4; |
|
Rectal exam |
Non contributory |
|
Integument |
intact without lesions masses or rashes. |
|
Neuro |
No obvious deficits and CN grossly intact II-XII |
Based on case number 2, answer the following questions:
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms.
5. Give rationales for each differential diagnosis.
6. What teachings will you provide?
7. Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.
Discussion3ADVhealthassessment.docx
Discussion Module 3- Skin, Eye, & Ear Disorders
Class: Nur 504 Advanced Health Assessment.
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your case number is # 2.
|
|
Case 1 |
Case 2 |
Case 3 |
|
Chief Complaint (CC) |
A 57-year-old man presents to the office with a complaint of left ear drainage since this morning. |
A 45-year-old female presents with a complaint of an itchy red rash on her arms and legs for about two weeks. |
A 11-year-old female patient complains of red left eye and edematous eyelids. Her mother states the child complains of “sand in my left eye.” |
|
Subjective |
Patient stated he was having pulsating pain on left ear for about 3 days. After the ear drainage the pain has gotten a little better. |
She has been going on a daily basis to the local YMCA with children for Summer camp. |
Patient noticed redness three days ago. Denies having any allergies. Symptoms have gotten worse since she noticed having the problem. |
|
Objective Data |
|||
|
VS |
(T) 99.8°F; (RR) 14; (HR) 72; (BP) 138/90 |
(T) 98.3°F; (RR) 18; (HR) 70, regular; (BP) 118/74 |
(T) 98.2°F; (RR) 18; (HR) 78; BP 128/82; SpO2 96% room air; weight 110 lb. |
|
General |
well-developed, healthy male |
healthy-appearing female in no acute distress |
well-developed, healthy, 11 years old |
|
HEENT |
EAR: (R) external ear normal, canal without erythema or exudate, little bit of cerumen noted, TM- pearly grey, intact with light reflex and bony landmarks present; (L) external ear normal, canal with white exudate and crusting, no visualization of tympanic membrane or bony landmarks, no light reflex EYE: bilateral anicteric conjunctiva, (PERRLA), EOM intact. NOSE: nares are patent with no tissue edema. THROAT: no lesions noted, oropharynx moderately erythematous with no postnasal drip. |
EYES: no injection, no increase in lacrimation or purulent drainage; EARS: normal TM: Normal |
EYES: very red sclera with dried, crusty exudates; unable to open eyes in the morning with the left being worse than the right |
|
Skin |
No rashes |
CTA AP&L |
CTA AP&L |
|
Neck/Throat |
no neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged; trachea midline |
mild edema with inflammation located on forearms, upper arms, and chest wall, thighs and knees; primary lesions are a macular papular rash with secondary linear excoriations on forearms and legs |
|
Based on case number # 2, answer the following questions:
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms.
5. Give rationales for your each differential diagnosis.
· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.
Discussion7AdvHealthAssessment.docx
Module 7 Discussion
Class: Nur 504 Advanced Health Assessment
Female Genitourinary, & Musculoskeletal
For this Discussion, you will take on the role of a clinician who is building a health history for case # 2
|
|
Case 2 |
|
Chief Complaint (CC) |
“I have pain during intercourse and urination” |
|
History of Present Illness (HPI) |
A 19-year-old female reports to you that she has “sores” on and in her vagina for the last three months. |
|
Drug Hx |
She tries to practice safe sex but has a steady boyfriend and figures she doesn’t need to be so careful since she is on the birth control pill |
|
Family Hx |
|
|
Subjective |
states “I have sores and bumps on the inner creases of my thighs and pelvic area”. “There is yellowish discharge from the sores that comes and goes” |
|
Objective Data |
|
|
VS |
temperature: 100.2°F; pulse 92; respirations 18; BP 122/78; weight 156 lbs, 25 lbs overweight; height 5′3″ |
|
General |
patient appears to have good hygiene; minimal makeup, pierced ears, no tattoos; well nourished (slightly overweight); no obvious distress noted |
|
HEENT |
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip. |
|
Lungs |
within normal limits, appropriate lung sounds auscultated, clear and equal bilaterally |
|
Card |
S1S2 without rub or gallop |
|
Breast |
• INSPECTION: no dimpling or abnormalities noted upon inspection • PALPATION: Left breast no abnormalities noted. Right breast: denies tenderness, pain, no abnormalities noted. |
|
Lymph |
Inguinal Lymph nodes: tenderness bilaterally, numerous, 1 cm in size |
|
Abd |
tender during palpation; the left lower quadrant was very tender during palpation; patient denies nausea or vomiting |
|
GU |
labia major and minor: numerous ulcerations, too many to count; some ulcerations enter the vaginal introitus; no ulcerations in the vagina mucosa; cervix is clear, some greenish discharge; bimanual exam reveals tenderness in left lower quadrant; able to palpate the left ovary; unable to palpate the right ovary; no tenderness; uterus is normal in size, slight tenderness with cervical mobility |
|
Integument |
|
|
MS |
Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation. |
|
Neuro |
No obvious deficits and CN grossly intact II-XII |
Once you received your case number, answer the following questions:
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms.
5. Give rationales for each differential diagnosis.
6. What teachings will you provide?
· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.