2 Case Studies for Nurse Practitioner Program ( SEC)

SUBJECTIVE:

Chief Complaint:

History of Present Illness: Pain level:

Medical History:

Onset Date:

Surgical History: No history of surgery

Social History: Single, no children. Denies any illegal drugs or alcohol use.

Family history: No family history.

Allergies: NKDA

Current Medications: No medications.

Smoking Status: Non-smoking, has never smoked.

Review of System:

General/Constitutional: Patient denies fever, chills, no weakness or fatigue. Denies any changes in appetite.

Psychiatric: Denies depression or anxiety, hallucinations, suicidal ideation.

HEENT: Denies headache, dizziness. No complaints of discomfort or pain when eating or chewing. Denies blurred/double vision, dry eyes. Denies hearing difficulty, ringing, earaches. Denies sinus trouble, nosebleed, snoring, frequent sneezing. Denies sore mouth, gum bleeding, hoarseness, teeth (cavities, dentures).

Neurologic/Psychiatric: Denies changes in memory. Denies dizziness, headache, syncope, numbness or tingling in the extremities.

Respiratory: Denies shortness of breath, cough, wheezing.

Cardiovascular: Denies chest pain, no SOB, no bleeding, no bruising, heart murmur, palpitations and edema.

Gastrointestinal: Denies change in bowel pattern, heartburn, anorexia, nausea, vomiting, constipation or diarrhea; c/o abdominal tenderness.

Genitourinary: Denies painful urination, denies incontinence, no changes in bladder pattern.

Musculoskeletal: Denies muscle pain, muscle aches, tenderness of the joints, muscular weakness or cramps, No contractures.

Lymphatics: Denies any swelling, enlarged, and tenderness in the lymph nodes.

Integumentary: Denies rashes, itchiness, bruises. No dryness, no sensitivity to sunlight, skin allergies.

Endocrinology: Denies reports of sweating. Denies cold or heat intolerance, denies polyuria, denies polydipsia.

Extremities: Denies contractures, denies any changes in range of motion, denies any changes with gait.

Vital Signs: Vitals Recorded on: 10//2020

Height: 66.00 in

Weight: 216.00 lbs.

BMI: 34.86

Blood Pressure: 121/84 mmHg

B/P Side: Left

B/P Position: Sitting

Pulse: 83 beats/min

Temperature: 98.6 Oral

Last Menstrual Period:

Objective Notes: Vitals intake by MA

OBJECTIVE:

Physical Exam:

General/Constitutional: No acute distress, no weight loss, dressed well. answers questions appropriately.

Neurological/Psychiatric: Patient is awake, alert, oriented to person, place and time; speech is clear and concise, appropriately, and maintains eye contact. Cranial nerves intact, memory, and expression are within normal limits. Muscle strength is 5/5 in both upper and lower extremities. Normal muscle tone, no loss of sensation; deep tendon reflexes are 2/4, no problems with motor coordination.

HEENT: Normocephalic, no facial swelling noted, no scalp lesion or tenderness; No thinning of the eyebrows noted. PERRLA, EOM intact, pink palpebral conjunctiva, present red reflex on fundoscopy; no periorbital swelling noted, no external ear lesions, tympanic membrane is translucent with positive cone of light on both ears, no ear discharge noted; midline nasal septum, no tongue lesions noted, no swelling of the tongue noted, no gum bleeding noted; tonsils and pharyngeal walls not swollen. Throat is pink, no exudate noted.

Neck: Supple, no masses, no tenderness, no tracheal deviation, no thyromegaly, no lymphadenopathy

Cardiovascular: Heart: S1, S2 with regular rate and rhythm; no murmurs noted.

Thorax and back: No spinal tenderness, and no costovertebral angle tenderness.

Lungs: Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. No adventitious sounds. No distress, no rales, rhonchi, wheezes or rubs

Gastrointestinal: Abdomen flat, soft, nontender, no scars; Normo-active bowel sounds in all 4 quadrants. Non-tender upon palpation, no guarding noted. Tympany noted on percussion; No masses or hepatosplenomegaly.

Genitourinary: No bladder distension, no dysuria, no hematuria.

Musculoskeletal: Full ROM seen in all 4 extremities, no deformities, no diffuse tenderness, or abnormalities.

Extremities: Full ROM throughout, no varicosities, no cyanosis, symmetrical/strong peripheral pulses, some tenderness. No edema or cyanosis noted. No clubbing of nails. All pulses present +3 throughout.

Lymphatics: No swelling of lymph nodes.

Integumentary: Skin warm and intact, no rashes, no discolorations.

ASSESSMENT:

Diagnosis & ICD-10 Codes:

1)

PLAN:

Laboratory test:

Procedures:

Medications:

Care Plan: I discussed the test results with the patient and pointed to the abnormal findings with relevance to the care plan. The above diagnoses and plan of care were discussed with patient. Patient expressed understanding and verbally agreed to adhere to and follow with each plan.

Patient Instructions: Reassured patient about the condition and findings, follow up after 2 weeks and/or when lab results become available.