NURS 680B Week 4 Discussion Advanced Health/Physical Assessment

NURS 680B Week 4 Discussion Advanced Health/Physical Assessment

 

Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, choice #2 19-year old male.

A 28-year old female presents with a “severe headache” for the past 9 hours. She states the pain is over the left temporal area and is “throbbing” in nature. These symptoms have occurred before but not as bad.

A 54-year old woman complain of left side drooling and facial drooping since earlier this morning.

A 64-year old diabetic man reports he has numbness and burning sensations in his toes for the past 6 months.

For the case you have chosen, post to the discussion:

Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.

In SOAP format, list:

Pertinent positive and negative information

Differential and working diagnosis

Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.

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Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.

In your peer replies, please reply to at least one peer who chose a different case study.

Identifying data: Patient C DOB: 7/28/1966 MR# Source and reliability of history: 54-year-old female, reliable historian. Demographics: • Gender: Female • Age: 54 • Marital status: N/A • Ethnicity: N/A • Social/occupation: N/A S: Subjective A 54-year old woman complain of left side drooling and facial drooping since earlier this morning. CC: Left side drooling and facial drooling since early this morning. HPI: Onset: When did it start? What were you doing when this episode occurred? Last time seen well? Location: Left side of face, does it radiate anywhere else? Duration: Since earlier this morning, have you experience these symptoms before? Characteristic: Left side drooling and facial drooping. Any other symptoms? Aggravating factors: Is there anything that makes it worse? Relieving factors: What have you tried to relieve your symptoms? Treatment: Have you taken any medication? If so, what medications did you tried? Have you tried any other treatment? Did it help? How long did you take it? How frequent? Severity: Any loss of sensation? Affecting any other parts of the body? PMH: • Childhood Illnesses: Did you have any childhood illnesses? • Surgical History: Any surgeries? • Hospitalizations/Accidents/Injuries: Have you had any hospitalizations, accidents, or injuries? • Transfusions: Any previous blood transfusions? Sexual history: • Number of sexual partners- How many sex partners have you had? • Sexual orientation – What is your sexual preference? • History of sexual transmitted infections- Any history of STI’s?