NR 601 Week 9 Case Study Discussions Physical Examination
NR 601 Week 9 Case Study Discussions Physical Examination
Discussion Part One (graded)
You are seeing S.F., a 74-year-old. Hispanic male in the office this morning for difficulty breathing.
Background:
S.F. presents with increased dyspnea on exertion that has become progressively worse over the last 3 days. You observe that he is using pursed lip breathing as he explains his chief complaint. He reports that he has been coughing up a moderate amount of thick, green sputum for approximately one week that was accompanied by a fever of 100.6 and chills. He took Ibuprofen 400 mg every 4 hours and increased his fluid intake for the last week.
Two days ago he noticed that the sputum is now yellow rather than green and that he has not experienced any more fever. Overall, he feels like he is getting better. However, the dyspnea on exertion developed three days ago without relief despite the use of his Spiriva HandiHaler. He reports that he lost his rescue inhaler and has not had it to use in over 2 months. NR 601 Week 9 Case Study Discussions Physical Examination
PMH:
COPD
Hypertension
Osteoarthritis
Current medications:
Asprin-81 daily
Cyclobenzaprine 10 mg prn
Meloxicam 15 mg daily
Metoprolol 25 mg daily
Spiriva HandiHaler daily as directed
Tramadol 50 mg daily prn
Surgeries:
Appendectomy as a child (date unknown)
2004-Left cataract extraction with intraocular lens placement
2008-Right cataract extraction with intraocular lens placement
Allergies: NKA
Influenza vaccine- October 2013
Pneumovax-2010
His last TD-can’t remember
Has not a TDAP/TD in 20 years
Screening History:
Last Colonoscopy was 2012-normal
Last dilated retinal and glaucoma exam was 2013
Social history:
Retired roofer-stopped working in 2004 due to arthritis and pain in his rotator cuff. Is married and lives with spouse. They have 4 grown children who live within a 10 mile radius of them. Currently smokes-is down to ½ pack cigarettes daily. Has smoked for 45 years total. NR 601 Week 9 Case Study Discussions Physical Examination
Family history:
Father is deceased and had a history of hypertension and diabetes; Mother is deceased and had a history of CAD/MI; Sister-history of colon cancer.
Discussion Part One:
Provide differential diagnoses (DD)with rationale.
Further ROS questions needed to develop DD.
Based on the patient data provided, choose geriatric assessment tools that would be appropriate to use in conducting a thorough geriatric assessment. Provide a rationale on why you are choosing these particular tools. NR 601 Week 9 Case Study Discussions Physical Examination
Description
Description
Purpose
The purpose of this assignment is for students to: -develop a genogram that provides an effective tool for gathering family data, -provide a visual portrayal of a patient’s family health history as the history pertains to the physical exam, -provide healthcare providers with a clearer picture of a patient’s non-modifiable risk factors, and -discuss their understanding of the patient’s genomic profile and the relationship to current health concerns. NR 601 Week 9 Case Study Discussions Physical Examination
Overview
A genogram is a visual and written representation of a history and physical. This genogram will be based on information obtained from the Shadow Health patient named Tina. As you are completing the Shadow Health: Health History assignment (see below), you will be able to ask Tina questions in order to gather information for the genogram. Consult Chapter 5, the Family History section and Figure 5-3, in the text for an example. NR 601 Week 9 Case Study Discussions Physical Examination
Directions
Develop a three-generation family medical tree for the Shadow Health patient Tina. -The three generations must include the patient, parents, and grandparents in order to receive full credit. -Identify family members, ages, relationships, and significant health history with identification of risk factors. -Identify deceased, divorced, or estranged family members and ages and causes of death of family members. NR 601 Week 9 Case Study Discussions Physical Examination