NURS 6512: Advanced Health Assessment Assignment Paper
My stomach hurts, I have diarrhea and nothing seems to help."
HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
PMH: HTN, Diabetes, hx of GI bleed 4 years ago
Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)NURS 6512: Advanced Health Assessment Assignment Paper
VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5'10"; WT 248lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: soft, hyperctive bowel sounds, pos pain in the LLQ
Left lower quadrant pain
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.NURS 6512: Advanced Health Assessment Assignment Paper
With regard to the SOAP note case study provided:
Review this week's Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study.NURS 6512: Advanced Health Assessment Assignment Paper
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.
To complete:NURS 6512: Advanced Health Assessment Assignment Paper
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?
What diagnostic tests would 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 3 different references from current evidence based literature.NURS 6512: Advanced Health Assessment Assignment Paper
Case Study 1- Photo #5 SUBJECTIVE DATA: Chief Complaint (CC): Dry, scaly patches on my skin. History of Present Illness (HPI): LD is a 24 year old Caucasian female who presents today with skin lesions on her lower legs bilaterally x 2 months. She reported that the “lesions seem to go away when her legs get some sun but then come back after some time”. The lesions are red and become dry and scaly. She has associated symptoms of itching. She has been putting Eucerin cream on the lesions but it hasn’t really helped. She feels the severity of her symptom discomfort is getting worse which brings her in today.NURS 6512: Advanced Health Assessment Assignment Paper. Medications: 1. Mesalamine 375 mg extended release capsules, 4 caps orally once a day in the morning 2. Valtrex 1000 mg tab, 2 tabs every 12 hours for 24 hours as needed for oral herpes. 3. Ortho-Novum 777 4. Over-the-counter Tylenol 325 mg tabs, 2 tabs as needed. 5. Fish oil 1000 mg daily Allergies: No known allergies. Past Medical History (PMH): 1. Ulcerative colitis 2. Herpes simplex virus type 1 Past Surgical History (PSH): 1. Colonoscopy Sexual/Reproductive History: She is sexually active, currently on oral contraception. Has single partner for last 2 years and no pregnancies. Personal/Social History: Denied smoking or illicit drug use, Drinks 3-4 beers or glasses of wine a week. Immunization History: Immunizations are up to date. NURS 6512: Advanced Health Assessment Assignment Paper
Significant Family History: Father diagnosed with prostate cancer at age 56. Lifestyle: She lives in the city and commutes to work. Works for an active travel company leading biking trips in France and the US. She has a master’s degree and rents an apartment with her boyfriend of 2 years. She is active and eats a healthy diet. She has a good support system of family and friends. Review of Systems: General: No recent weight gains or losses of significance. Patient denies fatigue. NURS 6512: Advanced Health Assessment Assignment Paper
She denies fever or chills. No sleep disturbances. HEENT: Denies any change in vision, double vision, or eye pain. Has never worn glasses or contacts. Denies any changes in hearing or ear pain. Denies sinus infections and epistaxis. Last dental exam 2 months ago for regular cleaning. Denies bleeding gums or toothache. Neck: No injury or pain. Breasts: Denies any breast changes. No history of masses, rashes, or lesions on breasts. Respiratory: Denies cough or sputum production. No dyspnea on exertion. NURS 6512: Advanced Health Assessment Assignment Paper
Cardiovascular/Peripheral Vascular: No history of murmur. No chest discomfort or palpitations. No edema or claudication. Gastrointestinal: + occasional abdominal pain in past, no nausea or vomiting, + irregular bowel pattern in past. Denies acid reflux. Genitourinary: Denies changes in urinary pattern. No incontinence, no history of STDs or HPV, patient is heterosexual. Musculoskeletal: No limitation in range of motion. No history of trauma or fractures. Denies arthritis. NURS 6512: Advanced Health Assessment Assignment Paper