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Tag Archives: What other objective findings would you look for?

October 29, 2024
October 29, 2024

Skin Eye & Ear Disorders

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.

 

Skin Eye & Ear Disorders

Case 1
Chief Complaint
(CC) 
A 57-year-old man presents to the office with a complaint of left ear drainage since this morning.
Subjective Patient stated he was having pulsating pain on left ear for about 3 days. After the ear drainage the pain has gotten a little better.
 VS (T) 99.8°F; (RR) 14; (HR) 72; (BP) 138/90
 General well-developed, healthy male
 HEENT EAR: (R) external ear normal, canal without erythema or exudate, little bit of cerumen noted, TM- pearly grey, intact with light reflex and bony landmarks present; (L) external ear normal, canal with white exudate and crusting, no visualization of tympanic membrane or bony landmarks, no light reflex EYE: bilateral anicteric conjunctiva, (PERRLA), EOM intact. NOSE: nares are patent with no tissue edema. THROAT: no lesions noted, oropharynx moderately erythematous with no postnasal drip.
 Skin No rashes
Neck/Throat no neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged;
trachea midline

 

Answer the following questions for your specific case study assigned:

  1. What other subjective data would you obtain specific to your case?
  2. What other objective findings would you look for?
  3. What diagnostic exams do you want to order?
  4. Name 3 differential diagnoses based on this patient’s presenting symptoms.
  5. Give rationales for each differential diagnosis.
  • Your initial post should be at least 500 words, formatted and cited in the current APA style with support from at least 3 academic sources.

Due Wednesday Oct 30 at 11:59pm

Skin, Eye, & Ear Disorders

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.

 

 

Case 1
Chief Complaint
(CC) 
A 57-year-old man presents to the office with a complaint of left ear drainage since this morning.
Subjective Patient stated he was having pulsating pain on left ear for about 3 days. After the ear drainage the pain has gotten a little better.
 VS (T) 99.8°F; (RR) 14; (HR) 72; (BP) 138/90
 General well-developed, healthy male
 HEENT EAR: (R) external ear normal, canal without erythema or exudate, little bit of cerumen noted, TM- pearly grey, intact with light reflex and bony landmarks present; (L) external ear normal, canal with white exudate and crusting, no visualization of tympanic membrane or bony landmarks, no light reflex EYE: bilateral anicteric conjunctiva, (PERRLA), EOM intact. NOSE: nares are patent with no tissue edema. THROAT: no lesions noted, oropharynx moderately erythematous with no postnasal drip.
 Skin No rashes
Neck/Throat no neck swelling or tenderness with palpation; neck is supple; no JVD; thyroid is not enlarged;
trachea midline

 

Answer the following questions for your specific case study assigned:

  1. What other subjective data would you obtain specific to your case?,
  2. What other objective findings would you look for?,
  3. What diagnostic exams do you want to order?,
  4. Name 3 differential diagnoses based on this patient’s presenting symptoms.,
  5. Give rationales for each differential diagnosis.,
  • Your initial post should be at least 500 words, formatted and cited in the current APA style with support from at least 3 academic sources.

Due Wednesday Oct 30 at 11:59pm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

October 3, 2024
October 3, 2024

Complain: I have pain during intercourse and urination”

History of illness: A 19-year-old female reports to you that she has “sores” on and in her vagina for the last three months.

 

Pain During Intercourse and Urination

Drug History: She tries to practice safe sex but has a steady boyfriend and figures she doesn’t need to be so careful since she is on the birth control pill

Subjective: states “I have sores and bumps on the inner creases of my thighs and pelvic area”. “There is yellowish discharge from the sores that comes and goes” Pain During Intercourse and Urination

Vitals: temperature: 100.2°F; pulse 92; respirations 18; BP 122/78; weight 156 lbs, 25 lbs overweight; height 5′3″

General: patient appears to have good hygiene; minimal makeup, pierced ears, no tattoos; well nourished (slightly overweight); no obvious distress noted

HEENT: Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.

Lungs: within normal limits, appropriate lung sounds auscultated, clear and equal bilaterally. Pain During Intercourse and Urination

Cardio: S1S2 without rub or gallop

Breast: INSPECTION: no dimpling or abnormalities noted upon inspection
• PALPATION: Left breast no abnormalities noted. Right breast: denies tenderness, pain, no abnormalities noted.

Lymph: Inguinal Lymph nodes: tenderness bilaterally, numerous, 1 cm in size

Abd: tender during palpation; the left lower quadrant was very tender during palpation; patient denies nausea or vomiting

GU: labia major and minor: numerous ulcerations, too many to count; some ulcerations enter the vaginal introitus; no ulcerations in the vagina mucosa; cervix is clear, some greenish discharge; bimanual exam reveals tenderness in left lower quadrant; able to palpate the left ovary; unable to palpate the right ovary; no tenderness; uterus is normal in size, slight tenderness with cervical mobility

MS: Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation. Pain During Intercourse and Urination

Neuro: No obvious deficits and CN grossly intact II-XII

Once you received your case number, answer the following questions:

  1. What other subjective data would you obtain?,
  2. What other objective findings would you look for?,
  3. What diagnostic exams do you want to order?,
  4. Name 3 differential diagnoses based on this patient presenting symptoms?,
  5. Give rationales for your each differential diagnosis.,
  6. What teachings will you provide?,
  • Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.

 

 

 

September 23, 2024
September 23, 2024

Health Assessment Week 5

Chief complaint -neck swelling”

History of Present Illness (HPI)- A 42-year-old African American female who refers that she has been noticing slow and progressive swelling on her neck for about a year. Also she stated she has lost weight without any food restriction

 

Health Assessment Week 5

PMH– negative

Past surgical History-Surgical removal of benign left breast nodule 2 years ago

Medication– none

Allergies- NKA

Subjective-Mild difficult to shallow, Neck feels tight, Pt states she feels Palpitations

V/S- B/P 158/90; Pulse 102; RR 20; Temp 99.2; Ht 5,4; wt 114; BMI 19.6

General-42-year-old female appears thin. She is anxious – pacing in the room and fidgeting, but in no acute distress

HEENT- Bulging eyes

NECK-Diffuse enlargement of the thyroid gland

Lungs-CTA AP&L

Cardiac-S1S2 without rub, Tachycardia

Abdomen-benign, normoactive bowel sounds x 4

GU-Non contributory

Extremities-no cyanosis, clubbing or edema

Integument-Thin skin, Increase moisture

Neuro-No obvious deficits and CN grossly intact II-XII

 

What other subjective data would you obtain?, What other objective findings would you look for?,

What diagnostic exams do you want to order?, Name 3 differential diagnoses based on this patient presenting symptoms?,

Give rationales for each differential diagnosis.,

post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

Health Assessment Week 5

Chief complaint -neck swelling”

History of Present Illness (HPI)- A 42-year-old African American female who refers that she has been noticing slow and progressive swelling on her neck for about a year. Also she stated she has lost weight without any food restriction

PMH– negative

Past surgical History-Surgical removal of benign left breast nodule 2 years ago

Medication– none

Allergies- NKA

Subjective-Mild difficult to shallow, Neck feels tight, Pt states she feels Palpitations

V/S- B/P 158/90; Pulse 102; RR 20; Temp 99.2; Ht 5,4; wt 114; BMI 19.6

General-42-year-old female appears thin. She is anxious – pacing in the room and fidgeting, but in no acute distress

HEENT- Bulging eyes

NECK-Diffuse enlargement of the thyroid gland

Lungs-CTA AP&L

Cardiac-S1S2 without rub, Tachycardia

Abdomen-benign, normoactive bowel sounds x 4

GU-Non contributory

Extremities-no cyanosis, clubbing or edema

Integument-Thin skin, Increase moisture

Neuro-No obvious deficits and CN grossly intact II-XII

 

What other subjective data would you obtain? What other objective findings would you look for?

What diagnostic exams do you want to order? Name 3 differential diagnoses based on this patient presenting symptoms?

Give rationales for each differential diagnosis. Health Assessment Week 5

post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.