Case 2 Ankle.docx
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A 46-year-old female presents with ankle pain in both ankles but more severe in the right after hearing a pop while playing soccer. She is able to bear weight but it is uncomfortable. The doctor will perform a physical exam of the ankles including special maneuvers to assess ligaments and joints to determine if there is a sprain or fracture. Differential diagnoses could include sprain, fracture, or tendon injury based on the mechanism of injury and Ottawa ankle rules will determine if additional testing is needed.
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Student ResponseScenario 1 GoutA 52-year-old obese Caucasia.docx
Student Response
Scenario 1: Gout
A 52-year-old obese Caucasian male presents to the clinic with a 2-day history of fever, chills, and right great toe pain that has gotten worse. Patient states this is the first time that this has happened, and nothing has made it better and walking on his right foot makes it worse. He has tried acetaminophen, but it did not help. He took several ibuprofen tablets last night which did give him a bit of relief. Past medical history positive or hypertension treated with hydrochlorothiazide and kidney stones. Social history negative for tobacco use but admits to drinking “a fair amount of red wine” every week. General appearance: Ill appearing male who sits with his right foot elevated. Physical exam remarkable for a temp of 101.2, pulse 108, respirations 18 and BP 160/88. Right great toe (first metatarsal phalangeal [MTP]) noticeably swollen and red. Unable to palpate to assess range of motion due to extreme pain. CBC and Complete metabolic profile revealed WBC 14,000 mm3 and uric acid 8.9 mg/dl. The APRN diagnoses the patient with acute gout.
1 of 2 Questions:
Describe the pathophysiology of gout.
<Type your response here>
2 of 2 Questions:
Explain why a patient with gout is more likely to develop renal calculi.
<Type your response here>
Scenario 2: Lyme Disease
Stan is a 45-year-old man who presents to the clinic complaining of intermittent fevers, joint pain, myalgias, and generalized fatigue. He noticed a rash several days ago that seemed to appear and disappear on different parts of his abdomen. He noticed the lesion below this morning and decided to come in for evaluation. He denies recent international travel and the only difference in his usual routine was clearing some underbrush from his back yard about a week ago. Past medical history non-contributory with exception of severe allergy to penicillin resulting in hives and difficulty breathing. Physical exam: Temp 101.1 ˚F, BP 128/72, pulse 102 and regular, respirations 18. Skin inspection revealed a 4-inch diameter bull’s eye type red rash over the left flank area. The APRN, based on history and physical exam, diagnoses the patient with Lyme Disease. She ordered appropriate labs to confirm diagnosis but felt it urgent to begin antibiotic therapy to prevent secondary complications.
Question:
What is Lyme disease and what patient factors may have increased his risk developing Lyme disease?
<Type your response here>
Scenario 3: Osteoporosis
A 72-year-old female was walking her dog when the dog suddenly tried to chase a squirrel and pulled the woman down. She tried to break her fall by putting her hand out and she landed on her outstretched hand. She immediately felt severe pain in her right wrist and noticed her wrist looked deformed. Her neighbor saw the fall and brought the woman to the local Urgent Care Center for evaluation. Radiographs revealed a Colles' fracture (distal radius with dorsal displacement of fragments) as well as radiographic ev.
Student ResponseScenario 1 GoutA 52-year-old obese Caucasia.docx
Student Response
Scenario 1: Gout
A 52-year-old obese Caucasian male presents to the clinic with a 2-day history of fever, chills, and right great toe pain that has gotten worse. Patient states this is the first time that this has happened, and nothing has made it better and walking on his right foot makes it worse. He has tried acetaminophen, but it did not help. He took several ibuprofen tablets last night which did give him a bit of relief. Past medical history positive or hypertension treated with hydrochlorothiazide and kidney stones. Social history negative for tobacco use but admits to drinking “a fair amount of red wine” every week. General appearance: Ill appearing male who sits with his right foot elevated. Physical exam remarkable for a temp of 101.2, pulse 108, respirations 18 and BP 160/88. Right great toe (first metatarsal phalangeal [MTP]) noticeably swollen and red. Unable to palpate to assess range of motion due to extreme pain. CBC and Complete metabolic profile revealed WBC 14,000 mm3 and uric acid 8.9 mg/dl. The APRN diagnoses the patient with acute gout.
1 of 2 Questions:
Describe the pathophysiology of gout.
<Type your response here>
2 of 2 Questions:
Explain why a patient with gout is more likely to develop renal calculi.
<Type your response here>
Scenario 2: Lyme Disease
Stan is a 45-year-old man who presents to the clinic complaining of intermittent fevers, joint pain, myalgias, and generalized fatigue. He noticed a rash several days ago that seemed to appear and disappear on different parts of his abdomen. He noticed the lesion below this morning and decided to come in for evaluation. He denies recent international travel and the only difference in his usual routine was clearing some underbrush from his back yard about a week ago. Past medical history non-contributory with exception of severe allergy to penicillin resulting in hives and difficulty breathing. Physical exam: Temp 101.1 ˚F, BP 128/72, pulse 102 and regular, respirations 18. Skin inspection revealed a 4-inch diameter bull’s eye type red rash over the left flank area. The APRN, based on history and physical exam, diagnoses the patient with Lyme Disease. She ordered appropriate labs to confirm diagnosis but felt it urgent to begin antibiotic therapy to prevent secondary complications.
Question:
What is Lyme disease and what patient factors may have increased his risk developing Lyme disease?
<Type your response here>
Scenario 3: Osteoporosis
A 72-year-old female was walking her dog when the dog suddenly tried to chase a squirrel and pulled the woman down. She tried to break her fall by putting her hand out and she landed on her outstretched hand. She immediately felt severe pain in her right wrist and noticed her wrist looked deformed. Her neighbor saw the fall and brought the woman to the local Urgent Care Center for evaluation. Radiographs revealed a Colles' fracture (distal radius with dorsal displacement of fragments) as well as radiographic ev.
Respond to at least two of your colleagues on 2different.docx
Respond
to
at least two
of your colleagues on
2
different days
who were assigned different case studies than you. Analyze the possible conditions from your colleagues' differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.
Main Post
Purpose:
This purpose of this assignment is to review case study #3 knee pain, and use the information to evaluate, form possible diagnoses, and practice documenting in soap format. Documenting in SOAP note format allows a practitioner to assess and document that the patient was treated with a holistic approach (Ball, Dains, Flynn, Solomon, & Stewart, 2019).
Case 3:
Knee PainA 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?
Patient Information:
ANW 15 1/19/04 M Caucasian
(CC):
“My knees hurt, sometimes I hear a clicking sound, and they get stuck.”
History of Present Illness (HPI):
Alexander (Alex) is a 15 year old Caucasian male who has come to the clinic complaining of pain in his knees. He states “sometimes it is just one knee that clicks and sometime it is both,” Alex states that his “knees get stuck or catch under the knee cap”. He rates the pain as 3/10 most days but after games the pain can be 6/10. He describes the pain as “dull and achy,” like I have done too much stuff. He states the pain started “a few weeks ago” and it was once in a while but now they hurt almost every day. He said his coach wants him to get his knees checked out before the next game.
Medications:
Motrin 200mg po Nightly.
Allergies:
KNA
Past Medical History (PMH):
None
Past Surgical History (PSH):
None
Sexual/Reproductive History:
Heterosexual. Identifies as male. Denies sexually active.
Personal/Social:
Alexander is a sophomore He plays on the basketball, baseball, soccer, football, track and wrestling team. He also loves to swim but states they do not have a team at the school. Alex states although he loves sports he wants to become a “sports doctor” and be a sports coach in his part time. Alex is proud of his 4.2 GPA and plans to graduate 1 year early and start college. He lives with his mother, adoptive father, maternal grandmother, and older sister. Alex says he has a half-brother that is 5 that leaves in Tennessee with his biological father. He states his biological father had a baby boy that died at birth a few years ago. .
I need a response to this assignment1 pagezero plagiarism.docx
I need a response to this assignment
1 page
zero plagiarism
three references
Patient Information:
CC : A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a "pop." She can bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottowa ankle rules to determine if you need additional testing?
Initials, N/A Age, 46 Sex, Female Race, not indicated
CC: Bilateral Ankle pain
HPI
: Pt c/o bilateral ankle pain, worse on R s/p hearing a “pop” while playing soccer this past weekend. Pt is able to bear weight, with some discomfort and was more concern about her R ankle.
Location: Bilateral ankle
Onset: Over the weekend
Character: Bilateral ankle pain, worse on the right. She was playing soccer over the weekend and heard a "pop."
Associated signs and symptoms: She can bear weight, but it is uncomfortable
Timing: over the weekend and heard a "pop. “while playing soccer
Exacerbating/ relieving factors: She can bear weight, but it is uncomfortable
Severity: She can bear weight, but it is uncomfortable
Current Medications
: Not indicated
Allergies:
None indicated
PMHx
: None indicated
Soc Hx
: played Soccer over the weekend
Fam Hx
: None Indicated.
GENERAL: No weight loss, fever, chills, weakness or fatigue indicated
HEENT: Eyes: PERRLA, no visual impairment blurred vision, double vision or yellow sclerae indicated. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat indicated
SKIN: No rash or itching nor discoloration indicated
CARDIOVASCULAR: No chest pain, chest pressure or SOB. No palpitations or edema indicated
RESPIRATORY: No shortness of breath, cough or difficulty breathing indicated
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood indicated
GENITOURINARY: No Burning on urination. No indication of Pregnancy. Last menstrual period not indicated.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control indicated
MUSCULOSKELETAL: bilateral ankle pain, worse on R. Positive pulses on both dorsalis and pedis bilaterally. Right ankle with 1+edema, erythema; and tenderness on palpation noted. No edema or erythema noted on the left ankle.
HEMATOLOGIC: No anemia, bleeding or bruising indicated
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: None indicated
ENDOCRINOLOGIC: No reported
ALLERGIES: NkDA
Peripheral Vascular: Right ankle with 1+edema, erythema; and tenderness on palpation noted. No edema or erythema noted on the.
Knee pain.docx
A 15-year-old male reports dull pain in both knees accompanied by clicking and a catching sensation under the kneecaps. His history includes knee pain for the past week that worsens with physical activity like walking to school. On examination, his knees show no signs of edema or tenderness but appear slightly misaligned. Differential diagnoses for his knee pain include Osgood-Schlatter disease, patellar dislocation, patella fracture, medial meniscus tear, and patellar chondromalacia. Further diagnostic tests like x-rays, CT scan, and MRI will help assess the tissues around the knees and rule out fractures or abnormalities.
Assignment Lab Assignment Assessing the Genitalia and Rectum.docx
Assignment: Lab Assignment: Assessing the Genitalia and Rectum
Photo Credit: Getty Images
Patients are frequently uncomfortable discussing with healthcare professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas.
In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.
To Prepare
Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
Based on the Episodic note case study:
Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
Consider what history would be necessary to collect from the patient in the case study.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify
at least five
possible conditions that may be considered in a differential diagnosis for the patient.
The Lab Assignment
Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential.
WK10 NURS 6512 ASSIGN.docx
This document provides instructions for a lab assignment analyzing an episodic note case study describing abnormal genital or rectal findings in a patient. Students are asked to review the case study and relevant learning resources to determine what additional history should be collected, which exams and tests should be conducted, and generate a differential diagnosis. The case study provided examines a 21-year-old woman presenting with painless bumps on her genital area, and the assessment identifies the condition as a chancre.
EpisodicFocused SOAP Note Exemplar (pls use this template).docx
Episodic/Focused SOAP Note Exemplar (pls use this template)
Focused SOAP Note for a patient with chest pain
S.
CC: “Chest pain”
HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms.
PMH: Positive history of GERD and hypertension is controlled
FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives.
SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years
ROS
General
--Negative for fevers, chills, fatigue
Cardiovascular
--Negative for orthopnea, PND, positive for intermittent lower extremity edema
Gastrointestinal
--Positive for nausea without vomiting; negative for diarrhea, abdominal pain
Pulmonary
--Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis
O.
VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
General
--Pt appears diaphoretic and anxious
Cardiovascular
--PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the
second right inter-costal space which radiates to the neck.
A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.
Gastrointestinal
--The abdomen is symmetrical without distention; bowel
sounds are normal in quality and intensity in all areas; a
bruit is heard in the right para-umbilical area. No masses or
splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.
Pulmonary
-- Lungs are clear to auscultation and percussion bilaterally
Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)
A.
Differential Diagnosis:
1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).
2) Angina (provide supportive documentation with evidence based guidelines).
3) Costochondritis (provide supportive documentation with evidence based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Assignment 1: Case Study Assignment: Assessing Neurological Symptoms
Case #2:
CASE STUDY 2: Numbness and Pain A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styli.
Recommended
Student ResponseScenario 1 GoutA 52-year-old obese Caucasia.docx
Student Response
Scenario 1: Gout
A 52-year-old obese Caucasian male presents to the clinic with a 2-day history of fever, chills, and right great toe pain that has gotten worse. Patient states this is the first time that this has happened, and nothing has made it better and walking on his right foot makes it worse. He has tried acetaminophen, but it did not help. He took several ibuprofen tablets last night which did give him a bit of relief. Past medical history positive or hypertension treated with hydrochlorothiazide and kidney stones. Social history negative for tobacco use but admits to drinking “a fair amount of red wine” every week. General appearance: Ill appearing male who sits with his right foot elevated. Physical exam remarkable for a temp of 101.2, pulse 108, respirations 18 and BP 160/88. Right great toe (first metatarsal phalangeal [MTP]) noticeably swollen and red. Unable to palpate to assess range of motion due to extreme pain. CBC and Complete metabolic profile revealed WBC 14,000 mm3 and uric acid 8.9 mg/dl. The APRN diagnoses the patient with acute gout.
1 of 2 Questions:
Describe the pathophysiology of gout.
<Type your response here>
2 of 2 Questions:
Explain why a patient with gout is more likely to develop renal calculi.
<Type your response here>
Scenario 2: Lyme Disease
Stan is a 45-year-old man who presents to the clinic complaining of intermittent fevers, joint pain, myalgias, and generalized fatigue. He noticed a rash several days ago that seemed to appear and disappear on different parts of his abdomen. He noticed the lesion below this morning and decided to come in for evaluation. He denies recent international travel and the only difference in his usual routine was clearing some underbrush from his back yard about a week ago. Past medical history non-contributory with exception of severe allergy to penicillin resulting in hives and difficulty breathing. Physical exam: Temp 101.1 ˚F, BP 128/72, pulse 102 and regular, respirations 18. Skin inspection revealed a 4-inch diameter bull’s eye type red rash over the left flank area. The APRN, based on history and physical exam, diagnoses the patient with Lyme Disease. She ordered appropriate labs to confirm diagnosis but felt it urgent to begin antibiotic therapy to prevent secondary complications.
Question:
What is Lyme disease and what patient factors may have increased his risk developing Lyme disease?
<Type your response here>
Scenario 3: Osteoporosis
A 72-year-old female was walking her dog when the dog suddenly tried to chase a squirrel and pulled the woman down. She tried to break her fall by putting her hand out and she landed on her outstretched hand. She immediately felt severe pain in her right wrist and noticed her wrist looked deformed. Her neighbor saw the fall and brought the woman to the local Urgent Care Center for evaluation. Radiographs revealed a Colles' fracture (distal radius with dorsal displacement of fragments) as well as radiographic ev.
Student ResponseScenario 1 GoutA 52-year-old obese Caucasia.docx
Student Response
Scenario 1: Gout
A 52-year-old obese Caucasian male presents to the clinic with a 2-day history of fever, chills, and right great toe pain that has gotten worse. Patient states this is the first time that this has happened, and nothing has made it better and walking on his right foot makes it worse. He has tried acetaminophen, but it did not help. He took several ibuprofen tablets last night which did give him a bit of relief. Past medical history positive or hypertension treated with hydrochlorothiazide and kidney stones. Social history negative for tobacco use but admits to drinking “a fair amount of red wine” every week. General appearance: Ill appearing male who sits with his right foot elevated. Physical exam remarkable for a temp of 101.2, pulse 108, respirations 18 and BP 160/88. Right great toe (first metatarsal phalangeal [MTP]) noticeably swollen and red. Unable to palpate to assess range of motion due to extreme pain. CBC and Complete metabolic profile revealed WBC 14,000 mm3 and uric acid 8.9 mg/dl. The APRN diagnoses the patient with acute gout.
1 of 2 Questions:
Describe the pathophysiology of gout.
<Type your response here>
2 of 2 Questions:
Explain why a patient with gout is more likely to develop renal calculi.
<Type your response here>
Scenario 2: Lyme Disease
Stan is a 45-year-old man who presents to the clinic complaining of intermittent fevers, joint pain, myalgias, and generalized fatigue. He noticed a rash several days ago that seemed to appear and disappear on different parts of his abdomen. He noticed the lesion below this morning and decided to come in for evaluation. He denies recent international travel and the only difference in his usual routine was clearing some underbrush from his back yard about a week ago. Past medical history non-contributory with exception of severe allergy to penicillin resulting in hives and difficulty breathing. Physical exam: Temp 101.1 ˚F, BP 128/72, pulse 102 and regular, respirations 18. Skin inspection revealed a 4-inch diameter bull’s eye type red rash over the left flank area. The APRN, based on history and physical exam, diagnoses the patient with Lyme Disease. She ordered appropriate labs to confirm diagnosis but felt it urgent to begin antibiotic therapy to prevent secondary complications.
Question:
What is Lyme disease and what patient factors may have increased his risk developing Lyme disease?
<Type your response here>
Scenario 3: Osteoporosis
A 72-year-old female was walking her dog when the dog suddenly tried to chase a squirrel and pulled the woman down. She tried to break her fall by putting her hand out and she landed on her outstretched hand. She immediately felt severe pain in her right wrist and noticed her wrist looked deformed. Her neighbor saw the fall and brought the woman to the local Urgent Care Center for evaluation. Radiographs revealed a Colles' fracture (distal radius with dorsal displacement of fragments) as well as radiographic ev.
Respond to at least two of your colleagues on 2different.docx
Respond
to
at least two
of your colleagues on
2
different days
who were assigned different case studies than you. Analyze the possible conditions from your colleagues' differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.
Main Post
Purpose:
This purpose of this assignment is to review case study #3 knee pain, and use the information to evaluate, form possible diagnoses, and practice documenting in soap format. Documenting in SOAP note format allows a practitioner to assess and document that the patient was treated with a holistic approach (Ball, Dains, Flynn, Solomon, & Stewart, 2019).
Case 3:
Knee PainA 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?
Patient Information:
ANW 15 1/19/04 M Caucasian
(CC):
“My knees hurt, sometimes I hear a clicking sound, and they get stuck.”
History of Present Illness (HPI):
Alexander (Alex) is a 15 year old Caucasian male who has come to the clinic complaining of pain in his knees. He states “sometimes it is just one knee that clicks and sometime it is both,” Alex states that his “knees get stuck or catch under the knee cap”. He rates the pain as 3/10 most days but after games the pain can be 6/10. He describes the pain as “dull and achy,” like I have done too much stuff. He states the pain started “a few weeks ago” and it was once in a while but now they hurt almost every day. He said his coach wants him to get his knees checked out before the next game.
Medications:
Motrin 200mg po Nightly.
Allergies:
KNA
Past Medical History (PMH):
None
Past Surgical History (PSH):
None
Sexual/Reproductive History:
Heterosexual. Identifies as male. Denies sexually active.
Personal/Social:
Alexander is a sophomore He plays on the basketball, baseball, soccer, football, track and wrestling team. He also loves to swim but states they do not have a team at the school. Alex states although he loves sports he wants to become a “sports doctor” and be a sports coach in his part time. Alex is proud of his 4.2 GPA and plans to graduate 1 year early and start college. He lives with his mother, adoptive father, maternal grandmother, and older sister. Alex says he has a half-brother that is 5 that leaves in Tennessee with his biological father. He states his biological father had a baby boy that died at birth a few years ago. .
I need a response to this assignment1 pagezero plagiarism.docx
I need a response to this assignment
1 page
zero plagiarism
three references
Patient Information:
CC : A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a "pop." She can bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottowa ankle rules to determine if you need additional testing?
Initials, N/A Age, 46 Sex, Female Race, not indicated
CC: Bilateral Ankle pain
HPI
: Pt c/o bilateral ankle pain, worse on R s/p hearing a “pop” while playing soccer this past weekend. Pt is able to bear weight, with some discomfort and was more concern about her R ankle.
Location: Bilateral ankle
Onset: Over the weekend
Character: Bilateral ankle pain, worse on the right. She was playing soccer over the weekend and heard a "pop."
Associated signs and symptoms: She can bear weight, but it is uncomfortable
Timing: over the weekend and heard a "pop. “while playing soccer
Exacerbating/ relieving factors: She can bear weight, but it is uncomfortable
Severity: She can bear weight, but it is uncomfortable
Current Medications
: Not indicated
Allergies:
None indicated
PMHx
: None indicated
Soc Hx
: played Soccer over the weekend
Fam Hx
: None Indicated.
GENERAL: No weight loss, fever, chills, weakness or fatigue indicated
HEENT: Eyes: PERRLA, no visual impairment blurred vision, double vision or yellow sclerae indicated. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat indicated
SKIN: No rash or itching nor discoloration indicated
CARDIOVASCULAR: No chest pain, chest pressure or SOB. No palpitations or edema indicated
RESPIRATORY: No shortness of breath, cough or difficulty breathing indicated
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood indicated
GENITOURINARY: No Burning on urination. No indication of Pregnancy. Last menstrual period not indicated.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control indicated
MUSCULOSKELETAL: bilateral ankle pain, worse on R. Positive pulses on both dorsalis and pedis bilaterally. Right ankle with 1+edema, erythema; and tenderness on palpation noted. No edema or erythema noted on the left ankle.
HEMATOLOGIC: No anemia, bleeding or bruising indicated
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: None indicated
ENDOCRINOLOGIC: No reported
ALLERGIES: NkDA
Peripheral Vascular: Right ankle with 1+edema, erythema; and tenderness on palpation noted. No edema or erythema noted on the.
Knee pain.docx
A 15-year-old male reports dull pain in both knees accompanied by clicking and a catching sensation under the kneecaps. His history includes knee pain for the past week that worsens with physical activity like walking to school. On examination, his knees show no signs of edema or tenderness but appear slightly misaligned. Differential diagnoses for his knee pain include Osgood-Schlatter disease, patellar dislocation, patella fracture, medial meniscus tear, and patellar chondromalacia. Further diagnostic tests like x-rays, CT scan, and MRI will help assess the tissues around the knees and rule out fractures or abnormalities.
Assignment Lab Assignment Assessing the Genitalia and Rectum.docx
Assignment: Lab Assignment: Assessing the Genitalia and Rectum
Photo Credit: Getty Images
Patients are frequently uncomfortable discussing with healthcare professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas.
In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.
To Prepare
Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
Based on the Episodic note case study:
Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
Consider what history would be necessary to collect from the patient in the case study.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify
at least five
possible conditions that may be considered in a differential diagnosis for the patient.
The Lab Assignment
Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential.
WK10 NURS 6512 ASSIGN.docx
This document provides instructions for a lab assignment analyzing an episodic note case study describing abnormal genital or rectal findings in a patient. Students are asked to review the case study and relevant learning resources to determine what additional history should be collected, which exams and tests should be conducted, and generate a differential diagnosis. The case study provided examines a 21-year-old woman presenting with painless bumps on her genital area, and the assessment identifies the condition as a chancre.
EpisodicFocused SOAP Note Exemplar (pls use this template).docx
Episodic/Focused SOAP Note Exemplar (pls use this template)
Focused SOAP Note for a patient with chest pain
S.
CC: “Chest pain”
HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms.
PMH: Positive history of GERD and hypertension is controlled
FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives.
SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years
ROS
General
--Negative for fevers, chills, fatigue
Cardiovascular
--Negative for orthopnea, PND, positive for intermittent lower extremity edema
Gastrointestinal
--Positive for nausea without vomiting; negative for diarrhea, abdominal pain
Pulmonary
--Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis
O.
VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
General
--Pt appears diaphoretic and anxious
Cardiovascular
--PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the
second right inter-costal space which radiates to the neck.
A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.
Gastrointestinal
--The abdomen is symmetrical without distention; bowel
sounds are normal in quality and intensity in all areas; a
bruit is heard in the right para-umbilical area. No masses or
splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.
Pulmonary
-- Lungs are clear to auscultation and percussion bilaterally
Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)
A.
Differential Diagnosis:
1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).
2) Angina (provide supportive documentation with evidence based guidelines).
3) Costochondritis (provide supportive documentation with evidence based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Assignment 1: Case Study Assignment: Assessing Neurological Symptoms
Case #2:
CASE STUDY 2: Numbness and Pain A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styli.
I need a respond to this assignmentthree referenceszero plag.docx
I need a respond to this assignment
three references
zero plagiarism
Case 3 : KNEE PAIN.
A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?
Assessing Musculoskeletal Pain: Knee
Patient Initials: MA Age: 15 years Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC):
“My knees hurt, panful and with clicking sound. I experience catching sensation under the patella. ” The additional history will be assessed by asking questions related to the onset of the pain in terms of acute or gradual, duration of the pain and its associated symptoms and previous treatment for the pain.
History of Present Illness (HPI):
MA is a high school sophomore who came to the doctor complaining of knee pain. He is an active basketball player for his school team. He started experiencing knee pain in the last week. He claims to be suffering clicking sounds from both knees.
Location:
bilateral knees.
Onset:
Eight days while playing basketball.
Character:
Dull intermittent pain.
Associated signs and symptoms:
A catching sensation under kneecaps.
Timing:
For the past 8 dyas.
Exacerbating/ relieving factors:
gets worst while patient treks to school. The pain subsides with mediciation rest and ice pack.
Severity:
7 on a pain scale of 1-10 after pain medication Ibuprofen 200mg 2 tabs orally was taken and 10/10 worst pain level after a trek to school.
Medication:
Ibuprofen.
Allergies:
No allergy to medication but allergic to shellfish.
Past Medical History (PMH):
The patient sprained his left knee four months ago, and history of Rheumatic fever during his early childhood.
Past Surgical History (PSH):
No history of medical surgery.
Sexual/Reproductive History:
None. The patient is not sexually active.
Personal/Social History:
Denies smoking, drinking alcohol, or using any other drugs.
Immunization History:
All immunizations are up to date as per the parents. Received flu vaccine 10/5/19.
Significant Family History:
MA lives with his parents. Both grandfathers have diabetes, his mother is obese. His two other siblings are healthy. The family has a history of obesity.
Review of Systems
: MA has presented a complaint of dull knee pain that he experiences in both knees. The pain is clicking and accompanied with a catching sensation under the patella. The pain mostly persists during physical activity.
OBJECTIVE DATA:
General
: MA is a healthy 15 years old who has maintained a healthy body. MA is alert and oriented and very active in school when it comes to basketball an.
Discussion post reply to the following soap noted case scenario-Respon.docx
Discussion post reply to the following soap noted case scenario.
Respond by analyzing Analyze the possible conditions from your colleagues' differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.
APA format with intext citation
2 to 3 scholarly references with in the last 5 years
Plagiarism free with Turnitin report
250-300 minimum word count
Case scenario # 1
Week 8, Mpofu Sibongile C
1/18/2023
Review of Case Study # 2 Ankle Pain SOAP Note.
Patient Information: Name: MF
Initials, MF Age: 46-year-old Sex: Female, Caucasian.
S.
CC : “My Ankles Hurts, worse on the right ankleâ€.
HPI : MF is a 46-year-old Caucasian female who presents to the clinic this morning with bilateral ankle pain, worse on the right foot it hurts and very uncomfortable. She reports pain started two days ago after playing soccer over the weekend, she says she heard a “popâ€. It is a throbbing pain, that gets worse when she bears weight on it when standing or walking but gets better when she applies ice and rest with feet elevated. She states the pain as constant all day, associated with swelling. She rates her pain as 3/10 left ankle but right ankle is 7/10.
Current Medication:
1. Ibuprofen 400 mg x 2 PO 8 hrly prn for pain. Has been taking it for 2 days ago.
2. Tylenol 650 mg PO 6 hourly for pain. Since last night.
3. Ice packs, twice daily for pain.
4. Fish oil 1200 mg PO, HS for pain
Allergies: No Known allergies to drugs nor food allergies .
PMH: MF is up to date with her immunization, has covid-19 vaccine in June 2022. (Pfizer). Second dose on September 15th, 2022. Tetanus vaccine a year ago but cannot recall the date. Is getting flu vaccine end of the month. Made up history. Sprained her ankle 2 years ago,2020. No previous surgeries.
Soc History : Â She is a high school sports teacher. Married for 6 years, no children. She enjoys outdoor activities walking, camping, playing soccer and shopping. She lives with her husband in a 3-bedroom house, secure community. She does not smoke but drinks alcohol, a glass of wine during dinner and beer during weekends only if no sports. Denies drugs use. She drives herself to work, wears seat belts, she only answers the phone using her Bluetooth. She eats healthy diet and exercises 3 times a week on her treadmill and plays sports (soccer) every Friday afternoon and Saturday from 4 pm to 6pm. She gets support from her husband and is a member of teachers support group.
Fam Hx :
1. Mother: 72 years. Type 2 diabetes, on diet control, diagnosed 3 years ago alive.
2. Father: Father 78 years with gout, is alive.
3. Sister: 40 years with arthritis alive
4. Maternal grandmother: died at 80 years from hypertension.
5. Maternal grandfather: died at 68 years from COPD.
6. Paternal grandfather: Died from heart attack at 70 years.
7. Paternal grandmother: died at 80 years, unknown cause, but had arthritis.
ROS :
General: MF appears healthy, she wei.
1.A 52-year-old obese Caucasian male presents to the clinic wit.docx
1.
A 52-year-old obese Caucasian male presents to the clinic with a 2-day history of fever, chills, and right great toe pain that has gotten worse. Patient states this is the first time that this has happened, and nothing has made it better and walking on his right foot makes it worse. He has tried acetaminophen, but it did not help. He took several ibuprofen tablets last night which did give him a bit of relief. Past medical history positive or hypertension treated with hydrochlorothiazide and kidney stones. Social history negative for tobacco use but admits to drinking “a fair amount of red wine” every week. General appearance: Ill appearing male who sits with his right foot elevated. Physical exam remarkable for a temp of 101.2, pulse 108, respirations 18 and BP 160/88. Right great toe (first metatarsal phalangeal [MTP]) noticeably swollen and red. Unable to palpate to assess range of motion due to extreme pain. CBC and Complete metabolic profile revealed WBC 14,000 mm3 and uric acid 8.9 mg/dl. The APRN diagnoses the patient with acute gout.
Question 1 of 2:
Describe the pathophysiology of gout.
QUESTION 2
1. A 52-year-old obese Caucasian male presents to the clinic with a 2-day history of fever, chills, and right great toe pain that has gotten worse. Patient states this is the first time that this has happened, and nothing has made it better and walking on his right foot makes it worse. He has tried acetaminophen, but it did not help. He took several ibuprofen tablets last night which did give him a bit of relief. Past medical history positive or hypertension treated with hydrochlorothiazide and kidney stones. Social history negative for tobacco use but admits to drinking “a fair amount of red wine” every week. General appearance: Ill appearing male who sits with his right foot elevated. Physical exam remarkable for a temp of 101.2, pulse 108, respirations 18 and BP 160/88. Right great toe (first metatarsal phalangeal [MTP]) noticeably swollen and red. Unable to palpate to assess range of motion due to extreme pain. CBC and Complete metabolic profile revealed WBC 14,000 mm3 and uric acid 8.9 mg/dl. The APRN diagnoses the patient with acute gout.
Question 2 of 2:
Explain why a patient with gout is more likely to develop renal calculi. 1 points
QUESTION 3
1. Stan is a 45-year-old man who presents to the clinic complaining of intermittent fevers, joint pain, myalgias, and generalized fatigue. He noticed a rash several days ago that seemed to appear and disappear on different parts of his abdomen. He noticed the lesion below this morning and decided to come in for evaluation. He denies recent international travel and the only difference in his usual routine was clearing some underbrush from his back yard about a week ago. Past medical history non-contributory with exception of severe allergy to penicillin resulting in hives and difficulty breathing. Physical exam: Temp 101.1 ˚F, BP 128/72, pulse 102 and regular, respirations .
Discussion 1Discussion Question 1Based on your performance a.docx
Discussion 1
Discussion Question 1
Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.
The history collection portion of these assignments seems to be the most challenging to me. There are so many questions, and sections, that is difficult to ask all the expected questions. I did fail to ask a few of the questions deemed to be important, according to the experts. The first question, “When you urinate, have you noticed: pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day or night or any changes in frequency?” This is an important question because spinal injury can result in issues with bowel or bladder control. These findings are “red flags” according to Goolsby and Grubbs (2015). Loss of bladder or bowel control could indicate the patient is suffering from Cauda Equina syndrome, which is a medical emergency that requires treatment to prevent long-term complications (Ahad, Elsayed, and Tohid, 2015).
The second question I omitted was, “Any other symptoms or concerns we should discuss?” This question is very useful to help patient’s talk about other issues they may be experiencing. During my personal clinical rotation, this question has often revealed a whole new problem the patient is experiencing.
Discussion Question 2
Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.
My physical exam of this patient was decent, but I was so focused on this patient’s current complaint that omitted some key assessments. I failed to auscultate that patient’s heart sounds, before moving on to something else. Cardiovascular assessment is essential on all patients, and should not be skipped. Many patients have underlying cardiovascular issues, that are only caught during physical examinations (Bickley, 2016).
I did not perform a breast exam on this patient, simply because her last mammogram was normal. This patient’s family history of breast cancer is a good indication for screening (Goolsby & Grubbs, 2015). Situations like these are difficult for me to decide if a portion of an exam should be omitted or not. In the beginning of this class I was doing unnecessary exams during my iHuman exams, so I attempt to be more focuses. This was not a good plan for this patient.
Discussion Question 3
Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.
The patient’s complaints of lower ...
This week we are covering HEENT. At this time you are assigned an
This document provides instructions for a case study assignment on HEENT. Students are assigned to complete an episodic/focused SOAP note on one of two case studies depending on whether their last name starts with A-J or K-Z. The case study for students with last names A-J involves a 20-year-old female college student named Lily presenting with a 3-day sore throat. Students are instructed to review learning resources, consider the history and exam needed to make a diagnosis, and provide a differential diagnosis listing of at least five possible conditions for the patient.
Differential Diagnosis for Skin Conditions Case Study.pdf
The document provides instructions for a case study assignment on differential diagnosis for skin conditions. Students will examine visual representations of various skin conditions and use differential diagnosis techniques to determine the most likely diagnosis. They will choose one skin condition to document in a SOAP note format, describing observations and formulating a differential diagnosis list of 3-5 possible conditions. The most likely diagnosis must be explained using references.
You are the information technology manager of an.docx
The IT manager of an 80-bed long-term care facility was tasked by the Board of Directors and CIO to create a 1-2 page report on private databases and doctor-patient privilege. The report aims to summarize the types of data stored in private health databases and whether it is protected by specific regulations or doctor-patient privilege. Private databases store confidential patient information like medical history and treatment plans. This data is regulated under laws like HIPAA which require security and privacy of sensitive medical information. Doctor-patient privilege legally protects confidential patient information and communications, though it has limits such as in response to court orders.
Your parents gave you up for adoption at a.docx
Your biological parents gave you up for adoption as a young child because they could not financially support you at the time. Thirty years later, they found you and one of your biological parents needs a kidney transplant. You are the best match to donate a kidney. You must determine whether you have a moral obligation to donate your kidney to your biological parent based on philosophical perspectives of ethics and your own cultural worldview.
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to questions.docx
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Europeans initially settled along the Atlantic coast for economic reasons like fishing and fur trading. England gradually took control of land held by other European countries like France and Spain through military conflicts and agreements. The early English colonies were strongly influenced by religion as different religious groups fled persecution in Europe and established colonies with religious freedom and self-governance in mind, though these colonies were still subject to oversight and laws passed in English Parliament.
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Friar John of Pian de Carpine and William of Rubruck each provided descriptions of the Mongol court in the 13th century. Using these primary sources, the essay argues that the Mongol Empire significantly shaped cross-cultural exchange through its interactions with other societies. The analysis focuses specifically on the assigned course materials regarding the Mongol Empire and the primary source descriptions of the Mongol court to make a persuasive case about the Empire's role in cultural diffusion across Eurasia.
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The document instructs students to watch two Frontline videos, "The Confessions" and "The Plea", and write a 2-4 page reaction paper about one of the videos. Students must watch "The Confessions" by week 11 and "The Plea" during week 11. Their paper should summarize the content of the chosen video and discuss their reaction to it based on course materials and personal experiences. The paper is due by the end of week 12.
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This document provides instructions for a short research paper on a topic related to World War II or the 1920s. The paper must be 3-5 double-spaced pages long using 12-point Times New Roman font with 1-inch margins. At least two credible academic sources must be cited using APA, MLA, or Chicago style. The paper should include a cover page with identifying information, bibliography, clear thesis statement, argument defending the thesis, and conclusion restates the argument. Acceptable topics include specific events like D-Day or social developments like flappers and fashion. The source material and all non-original content must be properly cited.
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Write a literary essay based on the.docx
The document provides instructions for a 1,000-1,200 word literary essay based on the memoir "Greetings From Bury Park" by Sarfraz Manzoor. Students must develop a thesis that answers either how the author uses America/Bruce Springsteen's music to show struggles OR what role the author's father plays in his struggles. The thesis must be supported using quotes from the memoir without outside research. Lenses from the "Lenses for Reading Literature" handout should also be applied. A sample thesis is given addressing how Springsteen/music show the author's desire for independence from his family and need to escape confines as a young Pakistani in Britain.
Why are the ancient legends of China of interest to.docx
The document discusses why ancient Chinese legends are of interest to historians. Historians can use both scholarly secondary sources and primary sources from ancient China to understand Chinese culture and history. Quotes from primary sources should be used to support arguments, while paraphrases and limited quotes from secondary sources provide context. A bibliography of all sources is also required.
Why and how did the loom large in focus on.docx
The document discusses how the role of women was an important issue in anti-colonial thought, using Egypt as a case study. It examines why women were often problematic for nationalism and what roles they played in anti-colonial struggles. The readings consider whether feminism and anti-colonial nationalism were complementary or contradictory. Key works analyzed include those by Kandiyoti, Baron, and Badran on the role of women in Egyptian nationalism and the development of feminism in relation to the anti-colonial movement.
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Why and how did the loom large in.docx
The document discusses how the "woman question" was an important issue in anti-colonial thought, using Egypt as a case study. It notes that women were often seen as a problem or issue for nationalism and asks what roles women played in anti-colonial struggles. It also questions whether feminism and anti-colonial nationalism were complementary or contradictory. It lists many relevant readings on these topics focused on historical cases in Egypt, India, and other regions that analyze the relationship between gender, nationalism, and colonial modernity.
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I need a respond to this assignmentthree referenceszero plag.docx
I need a respond to this assignment
three references
zero plagiarism
Case 3 : KNEE PAIN.
A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?
Assessing Musculoskeletal Pain: Knee
Patient Initials: MA Age: 15 years Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC):
“My knees hurt, panful and with clicking sound. I experience catching sensation under the patella. ” The additional history will be assessed by asking questions related to the onset of the pain in terms of acute or gradual, duration of the pain and its associated symptoms and previous treatment for the pain.
History of Present Illness (HPI):
MA is a high school sophomore who came to the doctor complaining of knee pain. He is an active basketball player for his school team. He started experiencing knee pain in the last week. He claims to be suffering clicking sounds from both knees.
Location:
bilateral knees.
Onset:
Eight days while playing basketball.
Character:
Dull intermittent pain.
Associated signs and symptoms:
A catching sensation under kneecaps.
Timing:
For the past 8 dyas.
Exacerbating/ relieving factors:
gets worst while patient treks to school. The pain subsides with mediciation rest and ice pack.
Severity:
7 on a pain scale of 1-10 after pain medication Ibuprofen 200mg 2 tabs orally was taken and 10/10 worst pain level after a trek to school.
Medication:
Ibuprofen.
Allergies:
No allergy to medication but allergic to shellfish.
Past Medical History (PMH):
The patient sprained his left knee four months ago, and history of Rheumatic fever during his early childhood.
Past Surgical History (PSH):
No history of medical surgery.
Sexual/Reproductive History:
None. The patient is not sexually active.
Personal/Social History:
Denies smoking, drinking alcohol, or using any other drugs.
Immunization History:
All immunizations are up to date as per the parents. Received flu vaccine 10/5/19.
Significant Family History:
MA lives with his parents. Both grandfathers have diabetes, his mother is obese. His two other siblings are healthy. The family has a history of obesity.
Review of Systems
: MA has presented a complaint of dull knee pain that he experiences in both knees. The pain is clicking and accompanied with a catching sensation under the patella. The pain mostly persists during physical activity.
OBJECTIVE DATA:
General
: MA is a healthy 15 years old who has maintained a healthy body. MA is alert and oriented and very active in school when it comes to basketball an.
Discussion post reply to the following soap noted case scenario-Respon.docx
Discussion post reply to the following soap noted case scenario.
Respond by analyzing Analyze the possible conditions from your colleagues' differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.
APA format with intext citation
2 to 3 scholarly references with in the last 5 years
Plagiarism free with Turnitin report
250-300 minimum word count
Case scenario # 1
Week 8, Mpofu Sibongile C
1/18/2023
Review of Case Study # 2 Ankle Pain SOAP Note.
Patient Information: Name: MF
Initials, MF Age: 46-year-old Sex: Female, Caucasian.
S.
CC : “My Ankles Hurts, worse on the right ankleâ€.
HPI : MF is a 46-year-old Caucasian female who presents to the clinic this morning with bilateral ankle pain, worse on the right foot it hurts and very uncomfortable. She reports pain started two days ago after playing soccer over the weekend, she says she heard a “popâ€. It is a throbbing pain, that gets worse when she bears weight on it when standing or walking but gets better when she applies ice and rest with feet elevated. She states the pain as constant all day, associated with swelling. She rates her pain as 3/10 left ankle but right ankle is 7/10.
Current Medication:
1. Ibuprofen 400 mg x 2 PO 8 hrly prn for pain. Has been taking it for 2 days ago.
2. Tylenol 650 mg PO 6 hourly for pain. Since last night.
3. Ice packs, twice daily for pain.
4. Fish oil 1200 mg PO, HS for pain
Allergies: No Known allergies to drugs nor food allergies .
PMH: MF is up to date with her immunization, has covid-19 vaccine in June 2022. (Pfizer). Second dose on September 15th, 2022. Tetanus vaccine a year ago but cannot recall the date. Is getting flu vaccine end of the month. Made up history. Sprained her ankle 2 years ago,2020. No previous surgeries.
Soc History : Â She is a high school sports teacher. Married for 6 years, no children. She enjoys outdoor activities walking, camping, playing soccer and shopping. She lives with her husband in a 3-bedroom house, secure community. She does not smoke but drinks alcohol, a glass of wine during dinner and beer during weekends only if no sports. Denies drugs use. She drives herself to work, wears seat belts, she only answers the phone using her Bluetooth. She eats healthy diet and exercises 3 times a week on her treadmill and plays sports (soccer) every Friday afternoon and Saturday from 4 pm to 6pm. She gets support from her husband and is a member of teachers support group.
Fam Hx :
1. Mother: 72 years. Type 2 diabetes, on diet control, diagnosed 3 years ago alive.
2. Father: Father 78 years with gout, is alive.
3. Sister: 40 years with arthritis alive
4. Maternal grandmother: died at 80 years from hypertension.
5. Maternal grandfather: died at 68 years from COPD.
6. Paternal grandfather: Died from heart attack at 70 years.
7. Paternal grandmother: died at 80 years, unknown cause, but had arthritis.
ROS :
General: MF appears healthy, she wei.
1.A 52-year-old obese Caucasian male presents to the clinic wit.docx
1.
A 52-year-old obese Caucasian male presents to the clinic with a 2-day history of fever, chills, and right great toe pain that has gotten worse. Patient states this is the first time that this has happened, and nothing has made it better and walking on his right foot makes it worse. He has tried acetaminophen, but it did not help. He took several ibuprofen tablets last night which did give him a bit of relief. Past medical history positive or hypertension treated with hydrochlorothiazide and kidney stones. Social history negative for tobacco use but admits to drinking “a fair amount of red wine” every week. General appearance: Ill appearing male who sits with his right foot elevated. Physical exam remarkable for a temp of 101.2, pulse 108, respirations 18 and BP 160/88. Right great toe (first metatarsal phalangeal [MTP]) noticeably swollen and red. Unable to palpate to assess range of motion due to extreme pain. CBC and Complete metabolic profile revealed WBC 14,000 mm3 and uric acid 8.9 mg/dl. The APRN diagnoses the patient with acute gout.
Question 1 of 2:
Describe the pathophysiology of gout.
QUESTION 2
1. A 52-year-old obese Caucasian male presents to the clinic with a 2-day history of fever, chills, and right great toe pain that has gotten worse. Patient states this is the first time that this has happened, and nothing has made it better and walking on his right foot makes it worse. He has tried acetaminophen, but it did not help. He took several ibuprofen tablets last night which did give him a bit of relief. Past medical history positive or hypertension treated with hydrochlorothiazide and kidney stones. Social history negative for tobacco use but admits to drinking “a fair amount of red wine” every week. General appearance: Ill appearing male who sits with his right foot elevated. Physical exam remarkable for a temp of 101.2, pulse 108, respirations 18 and BP 160/88. Right great toe (first metatarsal phalangeal [MTP]) noticeably swollen and red. Unable to palpate to assess range of motion due to extreme pain. CBC and Complete metabolic profile revealed WBC 14,000 mm3 and uric acid 8.9 mg/dl. The APRN diagnoses the patient with acute gout.
Question 2 of 2:
Explain why a patient with gout is more likely to develop renal calculi. 1 points
QUESTION 3
1. Stan is a 45-year-old man who presents to the clinic complaining of intermittent fevers, joint pain, myalgias, and generalized fatigue. He noticed a rash several days ago that seemed to appear and disappear on different parts of his abdomen. He noticed the lesion below this morning and decided to come in for evaluation. He denies recent international travel and the only difference in his usual routine was clearing some underbrush from his back yard about a week ago. Past medical history non-contributory with exception of severe allergy to penicillin resulting in hives and difficulty breathing. Physical exam: Temp 101.1 ˚F, BP 128/72, pulse 102 and regular, respirations .
Discussion 1Discussion Question 1Based on your performance a.docx
Discussion 1
Discussion Question 1
Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.
The history collection portion of these assignments seems to be the most challenging to me. There are so many questions, and sections, that is difficult to ask all the expected questions. I did fail to ask a few of the questions deemed to be important, according to the experts. The first question, “When you urinate, have you noticed: pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day or night or any changes in frequency?” This is an important question because spinal injury can result in issues with bowel or bladder control. These findings are “red flags” according to Goolsby and Grubbs (2015). Loss of bladder or bowel control could indicate the patient is suffering from Cauda Equina syndrome, which is a medical emergency that requires treatment to prevent long-term complications (Ahad, Elsayed, and Tohid, 2015).
The second question I omitted was, “Any other symptoms or concerns we should discuss?” This question is very useful to help patient’s talk about other issues they may be experiencing. During my personal clinical rotation, this question has often revealed a whole new problem the patient is experiencing.
Discussion Question 2
Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.
My physical exam of this patient was decent, but I was so focused on this patient’s current complaint that omitted some key assessments. I failed to auscultate that patient’s heart sounds, before moving on to something else. Cardiovascular assessment is essential on all patients, and should not be skipped. Many patients have underlying cardiovascular issues, that are only caught during physical examinations (Bickley, 2016).
I did not perform a breast exam on this patient, simply because her last mammogram was normal. This patient’s family history of breast cancer is a good indication for screening (Goolsby & Grubbs, 2015). Situations like these are difficult for me to decide if a portion of an exam should be omitted or not. In the beginning of this class I was doing unnecessary exams during my iHuman exams, so I attempt to be more focuses. This was not a good plan for this patient.
Discussion Question 3
Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.
The patient’s complaints of lower ...
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Differential Diagnosis for Skin Conditions Case Study.pdf
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