Shadow Healthy: Clinical Decision Making- Tina Jones

Shadow Healthy: Clinical Decision Making- Tina Jones Shadow Healthy: Clinical Decision Making- Tina Jones Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents for complete physical examination and evaluation for right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. Shadow Healthy: Clinical Decision Making- Tina Jones ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS General Survey Ms. Jones is alert and oriented, is seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene. Chief Complaint “My foot is killing me. It really hurts.” History of Present Illness Ms. Jones reports that two weeks ago she tripped while walking on concrete stairs outside, twisting her right ankle and “scraping” the ball of her foot. She sought care in a local emergency department where she had x-rays that were negative; she was treated with tramadol for pain. She has been cleansing the site when she showers. She has been applying antibiotic ointment with a Band-Aid. She reports that ankle swelling and pain have resolved but that the bottom of the foot is increasingly painful. The pain is described as “throbbing” and “sharp, shooting” with weight bearing. She states her ankle “ached” but is resolved. Pain is rated 5 to 6 out of 10 after a recent dose of tramadol. Pain is rated 9 with weight bearing. She feels she “cannot walk on it.” She reports that over the past two days the ball of the foot has become swollen and increasingly red; yesterday she noted some “blood and pus” oozing from the wound, requiring her to apply a bandage. She denies any odor from the wound. Her shoes feel tight. She has been wearing slip-ons. She reports subjective fevers over the past two days with an episode “just the other day I felt feverish, hot and cold.” She denies recent illness. Reports a 20-pound, unintentional weight loss over the past two months and increased appetite. Denies change in diet or level of activity. Medications Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (cramps) • Tramadol 50 mg PO BID prn (foot pain) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing: “when around cats,” last use three days ago) Allergies Penicillin: rash • Denies food and latex allergies • Cats: sneezing, itchy eyes, wheezing Medical History Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. She rarely uses her inhaler. She was exposed to cats a few days ago and had to use her inhaler once. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She used to take metformin, but she stopped taking it three years ago, stating that the pills made her gassy and “it felt like I was taking pills and checking my sugar all the time, it was a pain to get refills so I just stopped.” She doesn’t monitor her blood sugar. Last blood glucose was elevated at the hospital. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 6 weeks ago. For the past year cycles irregular (every 4-8 weeks) with heavy bleeding lasting 9-10 days. No current partner. Used oral contraceptives in the past. When sexually active, reports she did not use condoms. Never tested for HIV/AIDS. No history of STIs or STI symptoms. Last tested for STIs at age 22. Hematologic: Denies bleeding, bruising, blood transfusions and history of blood clots. Skin: Reports acne since puberty and bumps on the back of her arms when her skin is dry. Complains of darkened skin on her neck and increase facial and body hair. She reports a few moles but no other hair or nail changes. Health Maintenance Last Pap smear more than 4 years ago. Last eye exam in childhood. Last dental exam “a few years ago.” PPD (negative) ~2 years ago. No exercise. 24-hour Diet Recall: States that she skipped breakfast yesterday, and would typically have toast for breakfast, a sub sandwich for lunch, and a meatloaf or chicken with soup for dinner. Her snacks consist of pretzels and granola bars. Immunizations: Tetanus booster was received two weeks ago in emergency department, influenza is not current, and human papillomavirus has not been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine in college. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Does not use sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room. Family History Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 62, hypertension, high cholesterol, and type 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems. Shadow Healthy: Clinical Decision Making- Tina Jones Social History Never married, no children. Lived independently since age 20, currently lives with mother and sister in a single family home to support family after death of father one year ago, and anticipates moving out in a few months. Employed 32 hours per week as a supervisor at Mid-American Copy and Ship. She enjoys her work and was recently promoted to shift supervisor. She is a part-time student, in her last semester to earn a bachelor’s degree in accounting. She hopes to advance to an accounting position within her company. She has a car, cell phone, and computer. She receives basic health insurance from work, but is deterred from healthcare due to out-of-pocket costs. She enjoys spending time with friends, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She reports stressors relating to the death of her father and balancing work and school demands, and finances. She states that “staying organized, trying to plan, and attending church” help her to cope. No tobacco. Occasional cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking “a few” drinks per episode. She drinks 4 caffeinated drinks per day (diet soda). No foreign travel. No pets. Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. She plans on getting married and having children someday. Create a differential diagnosis list based on the information gathered about this case. Review of System Reports headaches that occur weekly with reading for the past few years. The headache lasts a few hours and is relieved with acetaminophen and sleep. Headaches are described as a “tight and throbbing feeling behind the eyes.” Denies head and neck trauma, brain cancer, migraines, seizures, dizziness, hair loss, and syncope. Ears: Denies difficulty hearing, tinnitus, ear pain, discharge, and loss of balance. Denies history of chronic otitis media and perforated tympanic membrane. Eyes: Complains of blurred vision associated with “reading and studying,” which has worsened over the past few years. No visual acuity testing since childhood. Does not wear corrective lenses. Reports eye redness and itching associated with exposure to cats. Denies discharge, pain, and diplopia. Denies glaucoma and congenital cataracts. Nose: Rhinitis and congestion related to cat allergy. Denies sinus problems, frequent colds/infections, and epistaxis. Throat, Mouth, Neck: Denies sore throat, dysphagia, and changes to voice quality. Denies dental pain or problems, oral lesions, and dry mouth, and changes in taste. Denies goiter, hyper/hypothyroidism. Physical Examination Normocephalic, atraumatic with no masses to palpation. Full distribution of hair on scalp, coarse hair noted on lateral face, chin, and upper lip. Eyebrows intact. Facial expression relaxed and symmetric without tics or drooping. No maxillary or frontal sinus tenderness. TMJ vertical and lateral movements smooth and symmetric. No clicking or crepitus. Ears: Normal shape without deformities, Darwin tubercle, redness or scaling. Auditory canals without edema or erythema. Tympanic membranes bilaterally pearly gray and intact with cone of light and bony landmarks visualized. No tenderness elicited when tragus palpated. No lesions noted. Hearing intact to whisper. Weber without lateralization. Rinne AC > BC bilaterally. Eyes: Skin free of redness, scaling or lesions. No entropion, ectropion, or edema noted. No pain elicited with palpation of the lacrimal gland, no discharge or pain noted with palpation of the lacrimal sac. PERRLA, anicteric sclera, conjunctiva pink and moist. EOMI, peripheral vision intact, 20/20 acuity left eye, 20/40 acuity right eye. Ophthalmologic examination reveals well-defined bilateral discs. Cotton wool spots and dot-and-blot hemorrhages scattered throughout right fundus. No lesions or exudates visualized in left fundus. No nicking, crossing changes, or papilledema seen bilaterally. Nose: Nose midline without deviation. Nasal mucosa pink, no exudates or polyps appreciated, inferior turbinates pink and moist. Frontal and maxillary sinuses not tender to palpation and percussion. Throat, Mouth, Neck: Oral mucosa pink, moist and intact. Uvula rises midline. Gag reflex intact. No dental caries. Velvety, hyperpigmentation noted circumferentially on distal neck near folds. Symmetric, midline without torticollis. Active range of motion – flexion, extension, rotation and lateral bending. Neck supple, without lymphadenopathy. Thyroid smooth and symmetric with no nodules or enlargement. No thyroid bruit. Create a differential diagnosis list based on the information gathered about this case. ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS Review of System History of poorly controlled asthma. Asthma diagnosed at age 2 1/2. Rarely uses inhaler. Uses albuterol inhaler when around cats. Was exposed to cats a few days ago and had to use inhaler once at that time. Last hospitalized for asthma in high school. Never intubated. Denies history of pneumonia, tuberculosis, and chronic bronchitis. Denies chest pain, dyspnea, current wheezing, hemoptysis, or recent cough. Physical Examination Respiratory rate: 22. Respirations easy and regular, able to speak in complete sentences. Skin without cyanosis. Normal trapezius muscle development. No scoliosis, kyphosis, pectus excavatum, or carinatum. Chest symmetric with equal expansion. AP < transverse diameter. Sternum midline without pectus excavatum or carinatum. Scapula equal and symmetric. Anterior and posterior chest wall is symmetric without lesions. Spine midline without kyphosis or scoliosis. Fremitus present and symmetric over all lobes. All lung fields resonant to percussion. Anterior lungs clear to auscultation, expiratory wheezes in posterior bilateral lower lobes. Absent bronchophony. O2 Sat 96% on room air. Bedside Spirometry: FVC 3.91 L; FEV1 3.15 L; FEV1/FVC Ratio: 80.56%. Create a differential diagnosis list based on the information gathered about this case. Review of System History of type 2 diabetes. Denies cough, chest pain, palpitations, dyspnea on exertion, orthopnea paroxysmal nocturnal dyspnea, peripheral edema, varicosities, and pain in lower extremities. Reports no blanching in fingertips when exposed to cold. Physical Examination Pulse 86. Blood pressure 176/84. No pulsations noted on inspection of chest and abdomen. S1 and S2, no murmurs, gallops, or rubs, regular rate and rhythm. No heaves, lifts, or thrills palpated over cardiac landmarks. Point of maximal impulse palpable at 5th intercostal space at midclavicular line. No jugular venous distention. Jugular venous pressure measured as 1 cm H20. Temporal and carotid pulses 2+, no thrill appreciated. Peripheral pulses 2+ throughout except right dorsalis pedis and posterior tibialis 1+ (obscured by local edema). 1+ edema noted on right lower leg. Capillary refill < 2 seconds on bilateral fingers and toes. Ankle-brachial index 0.96. Shadow Healthy: Clinical Decision Making- Tina Jones Create a differential diagnosis list based on the information gathered about this case. Gastrointestinal: Denies digestive problems, reflux, dysphagia, nausea, vomiting, diarrhea, constipation, changes in bowel habits, jaundice, abdominal pain, and bloody stools. Denies gallbladder and liver disease. Reports polyphagia, polydipsia, polyuria, and nocturia for past month. Reports unintentional weight loss of 20 lbs over the last 2 months. Usual diet consists of toast or smoothie for breakfast, sub sandwich at lunch, meatloaf or casserole for dinner, pretzels or granola for a snack. Eats fast food a “few times per week”, one serving vegetables per day. Caffeine: Denies coffee and tea, drinks 4 diet colas/day. Genitourinary: Denies flank pain, dysuria, urgency, and cloudy urine. Denies history of recurrent urinary tract infections and kidney stones. Denies vaginal discharge and vaginal itching. Menses irregular. No history of sexually transmitted infections. No pregnancies. Physical Examination Protuberant abdomen with striae noted across lower quadrants. No pulsations or peristalsis noted on inspection. Abdomen soft, nontender, and nondistended. Bowel sounds normoactive in all four quadrants. Tympanic to percussion in all quadrants. No masses or organomegaly palpated. Liver span percussed as 7 cm on midclavicular line, and palpated 1 cm below right costal margin. No masses, guarding, or rebound noted with deep palpation. Create a differential diagnosis list based on the information gathered about this case. Review of System Reports limited weight-bearing ability on injured foot. Right ankle sprain two weeks ago, now resolved. Patient reports persistent right ankle stiffness. Reports “crick in my neck.” Has experienced limping with recent injury. Denies history of fractures, gout, and arthritis. Denies myalgias and arthralgias. Denies back and neck pain and trauma. Denies generalized weakness. Does not exercise regularly. Physical Examination Muscle tone and bulk symmetric. No masses or deformities. No scoliosis, kyphosis, or lordosis. No cyanosis or pallor. No joint swelling. Full range of motion in all joints with 5/5 strength in cervical spine and all four extremities with exception of right ankle. Right ankle displays decreased range of motion and 4/5 strength. On plantar surface of the right foot an open wound is noted, it is inferior to the base of the first and second metatarsal. The wound is oval shaped and measures 2 cm x 1.5 cm, depth is 2.5 mm. Wound bed is beefy red with a whitish area at the center of the lesion, wound edges are irregular and appear white and moist. There is erythema surrounding the wound. There is a small amount of local edema. No drainage or odor appreciated. Create a differential diagnosis list based on the information gathered about this case. Review of System Headaches occur once a week behind the eyes with prolonged reading, resolved with acetaminophen and sleep. Denies fainting, dizziness, vertigo, weakness, syncope, numbness, tingling, tremors, seizures, and paralysis. Reports occasional clumsiness. Denies history of traumatic brain injury and meningitis. Denies recent changes in memory and mood changes. Physical Examination Cerebellar functions intact as evidenced by smooth and coordinated rapid alternating movements in bilateral upper extremities, and coordinated finger-to-nose and heel-to-skin movements. Unable to assess gait and balance due to right foot injury. Sensation intact to light touch and accurate perception of sharp and dull touch in all four extremities. No sensation of monofilament on distal plantar surfaces bilaterally, sensation intact on heels. Stereognosis and graphesthesia intact bilaterally. Proprioception intact in upper and lower extremities. Deep tendon reflexes: 2+ bilateral biceps, brachioradialis, triceps, patellar and Achilles. Create a differential diagnosis list based on the information gathered about this case. Reports recent grief and insomnia related to father’s death. Reports anxiety related to school tests and finances. Denies current depression, insomnia, change in mood, concentration or attention, and suicidal or homicidal ideation. Denies amnesia and dementia. Denies changes in remote or recent memory, and confusion. Reports no history of mental illness. Physical Examination Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation and is cooperative. Mood is pleasant. No tics or facial fasciculation. Speech is fluent, words are clear. Serial 7’s accurate. Recent and remote memory intact. Abstract thinking, attention, comprehension, vocabulary, and judgment are appropriate and intact. Create a differential diagnosis list based on the information gathered about this case. … Shadow Healthy: Clinical Decision Making- Tina Jones Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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