NU610 Advanced Health Assessment
Unit 6 Assignment
This week for your case studies you will document the Chief Complaint, HPI, ROS, relevant histories, and the objective data set on a word document and submitted to Canvas on three (3) patients seen in the clinical setting utilizing the same format as on previous case study assignments.
A 50-year-old man comes to your office for a routine physical examination. He is a new patient to your practice. He has no significant medical history and takes no medications regularly. He states his father died at the age of 73 of a heart attack. His mother is alive at the age of 80. She has hypertension. He has two younger siblings with no known chronic medical conditions. He does not smoke, drink alcohol, use any recreational drugs and does not exercise. On examination his blood pressure is 126/82, pulse is 80 beats/min, respiratory rate is 18. Height is 67 inches and weight is 190lbs.
A 53-year-old man presents to your office for an acute visit because of coughing and shortness of breath. He is well known to you because of multiple office visits in the past few years for similar reasons. He has a chronic cough but reports that the past 2 days it has worsened. His sputum has changed from white to green in color, and he has had to increase the albuterol inhaler use. He denies having a fever, chest pain, peripheral edema. He does have a history of hypertension, peripheral vascular disease, and 2 hospitalizations for pneumonia in the past 5 years. He has a 60-pack year history of smoking and continues to smoke 2 packs per day. On examination he is in moderate respiratory distress. His temperature is 98.4, blood pressure 152/95, pulse 98, respirations 24, O2 is 94% on room air. His lung exam is significant for diffuse expiratory wheezing and a prolonged expiratory phase of respiration. There are no signs of cyanosis. The remainder of his examination I normal.
A 40-year-old white male presents to your office complaining of left knee pain that has started last night. He says that the pain started suddenly and was severe within about 3 hours’ time. He denies injury, fever, systemic symptoms, or prior episodes. He has a history of hypertension and does take hydrochlorothiazide to control it. He admits to consuming a large amount of wine with dinner last night.
Upon examination his temperature is 98, pulse is 90, respirations are 22 and blood pressure is 129/88. Heart and lung examinations are unremarkable. The patient is reluctant to flex the left knee and does wince with pain at touch. He has passive range of motion. The knee is edematous, hot to touch, and has erythema of the overlying skin. No crepitation or deformity is apparent. No other joints are involved. Inguinal lymph notes are not enlarged.
A 40-year-old woman presents with 10 episodes of watery, non-bloody diarrhea that started last night. She vomited twice last night but has been able to tolerate liquids today. She is complaining of intermittent abdominal cramping. She also reports having muscle aches, weakness, headache, and low-grade fever. She states her son has had the same symptoms that started this morning. She has no significant medical history, denies surgeries, and does not take medications. She does not smoke, use alcohol, or illicit drugs. She does report that her and her family returned home yesterday after spending a week in Cancun.
On examination she is not in acute distress, blood pressure is 110/60, pulse 98, respiratory rate is 16, and temperature is 99.1. Bowel sounds are hyperactive, and her abdomen is mildly tender throughout but there is no rebound tenderness and no guarding. Her mucous membranes are dry. A rectal examination is normal, and stool is guaiac negative.
A 46-year-old white female presents with concerns about a mole on her face. She says that it has been there for years, but her husband wants her to have it checked. She denies any pain, itching or bleeding from the site. She has no significant past medical history, takes no medications and has no allergies. She has no history of skin cancer in her family. She reports she is a librarian at the local school.
Upon examination the patient is afebrile and appears slightly younger than her stated age. A skin examination reveals a non-tender, symmetric, 4mm papule that is uniformly reddish brown in color. The lesion is well circumscribed, and the surrounding skin appears normal. There are no other lesions in the area.
A 46-year-old female with a medical history of Multiple Sclerosis complains of constantly feeling tired even after a period of rest or sleep. She was diagnosed with MS 3 years ago and has been taking interferon to treat. As a wife and mother of 2 with a full-time job, she states that by the end of the day she has no energy whatsoever. The patient explains that she began noticing her lack of energy and tiredness a few months back, but it has gotten progressively worse. She also mentions that she has missed several days at work over the last 4 weeks because after getting showered and dressed, she had no energy left to go to work.
A 35-year-old male presents with the onset of acute low back pain. He was doing some yard work, including pulling out large bushes, when he experienced the acute onset of low back pain, radiating down the back of the left leg. Since then, the pain has worsened in intensity, and he is having difficulty bearing weight on the leg. He initially took 800 mg ibuprofen, which provided a small degree of relief, but he has not taken any medication since the problem initially occurred.
The patient has no significant medical history. His general physical examination is within normal limits. On neurological examination, he has severe pain with active movement of the lower extremity, but only minimal pain with passive movement of the lower extremity. He has a positive straight leg raise but no other neurological deficits.
A 43-year-old female presents to the clinical with a productive cough for the last 3 weeks. She notices that she has had a fever off and on over that time and coughs so much that she has chest pain. She reports having a mild sore throat and nasal congestion. She has no history of asthma or any chronic lung diseases. She denies nausea, vomiting diarrhea and recent travel. She denies smoking, alcohol, or illicit drug use. Upon examination temperature is 98.6, pulse 96, blood pressure 124/82 and respirations are 18. O2 sat is 99% on room air. Head, ears, eyes, nose, and throat examination reveal no erythema. Neck examination is negative. Chest examination reveals occasional wheezes but normal air movement.
A 64 year old white male presents for a routine evaluation. His only complaint is of fatigue over the past 2 to 3 months although he has had no changes in diet of lifestyle. He does report that he has never smoked and admits to an “occasional beer with the guys”. He has consumed a little more since retiring a year ago and admits to 2-3 now a day. He occasionally has headaches on the day after a night of heavier drinking. The headaches are relieved by over the counter non-steroidal anti-inflammatory medication (NSAID). While talking to him you notice no distress you note a 4-pound weight loss since his last visit 6 months ago and an increase in his pulse with a blood pressure of 129/81. Upon exam you notice paleness of his conjunctivae, but the rest of his examination is unchanged from his last visit. You perform a digital rectal exam and find a smooth normal size prostate and some soft, reducible protrusions within the internal sphincter along with guaiac positive stools.
A 30-year-old female presents with a complaint of headaches frequently. She reports that she has had them since she was a teenager, but they have become more debilitating recently. The episodes occur once or twice a month and last for up to 2 days. The pain begins in the right temple or the back of the right eye and spreads to the entire scalp over a few hours. She describes the pain as a sharp, throbbing sensation that gradually worsens and is associated with sever nausea. Several factors aggravate the pain including loud noises and movement. She has taken several over the counter medication for the pain but the only thing that makes it better is going to sleep in a dark quiet room. A thorough history reveals her mother suffers from migraines. Her vital sighs general examination and neurologic examination are all with in normal limits.
NU610 Advanced Health Assessment