Case Studies Assignment Discussion Paper

Posted: December 2nd, 2022

Case Studies Assignment Discussion Paper

Unit 5 Assignment – Case Studies

Subjective Data

•    Chief Complaint: “I came for annual wellness visit.”
•    History of Present Illness: H.N is a 29-year-old female who presents to the clinic for an annual wellness visit. She notes that she has no current complaints or health concerns. She admits to taking Ibuprofen 400mg for headaches occasionally. Her last hospital visit was 5 months ago when she was treated for PCOS.
•    Past Medical History: Patient reports she was diagnosed with PCOS 5 months ago and was treated with Yaz birth control pills.
•    Allergy: NKDA. Denies food or seasonal allergies. Case Studies Assignment Discussion Paper
  

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•    Medication Reconciliation: Patienttakes Ibuprofen 400mg for headache occasionally. She stopped using Yaz one month ago after achieving regular menstrual cycles.
•    Social History: H.N. has only just started her career as a high school teacher, and she is simultaneously working towards earning a Master’s degree in education. She is the firstborn child of her parents and only has a younger sister. She is not married and does not have any children. She reports that she lives alone in a rental apartment. She identifies as heterosexual and has one partner with whom she has sexual relations. She states that she experienced menarche at the age of 13, and her first sexual encounter occurred when she was 16 years old. The last menstrual period occurred a week ago, with a cycle length of 28 days and a menstrual flow of 5 days. Admits to having a drink or two while they are out with her friends occasionally. Denies ever having used cigarettes or illegal drugs. Swimming and being involved in the activities of her church are two of her favorite hobbies.
•    Family History:  Case Studies Assignment Discussion Paper

Mother- age 51, hypertension

Father- age 56, type 2 diabetes, elevated cholesterol

Maternal grandmother: deceased at age 84 of stroke, history of hypertension

Maternal grandfather: age 85, dementia

Paternal grandmother: age 81, elevated cholesterol

Paternal grandfather: died at age 56 of a car accident, history of obesity

Sister: age 23, healthy.

•    Health Promotion: Patient does not smoke or use illegal substances. She identifies three swimming sessions a week as part of her routine. Consumes a significant amount of veggies as well as whole grains. Patient is diligent about keeping her appointment for her yearly checkup on her overall wellness. She has had all of the recommended immunizations, including the meningococcal vaccination and the COVID vaccine, which she received this year. Booster shot for tetanus was given within the past year. Goes for regular eye and dental exams. Case Studies Assignment Discussion Paper
  

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•    Review of systems
• General: denies fever, chills, fatigue, or weight changes
• HEENT: Denies headache or history of head injury. Denies eye pain, itching, or vision problems. Denies ear pain, discharge, or hearing problems. Denies sore throat or swallowing problems.
• Respiratory: Denies cough, wheezing or shortness of breath
• Cardiovascular: Denies chest pain, palpitations or edema
• Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, or constipation.
• Genitourinary: Denies incontinence, dysuria, polyuria, vaginal discharge, or bleeding.
• Musculoskeletal: Denies muscle pain, injury, swelling or weakness
• Neurological: Denies dizziness, seizures, loss of coordination, or sense of disequilibrium
• Psychiatric: Denies history of depression, anxiety, or sleep problems. Denies suicidal ideation.
• Integumentary: Denies rash, lesions, or scars Case Studies Assignment Discussion Paper

Objective Data

•    Vital Signs: BP 116/71, HR 76, RR17, Ht 5ft 4in, Wt 134 lbs, BMI 22.9.
•    General: Pleasant appearing patient, in no acute distress.Alert and oriented x4. Well dressed and well nourished. Clear and coherent speech.
•    HEENT: Normocephalic and atraumatic head with normal hair distribution. Pink conjunctiva, white sclera, intact extraocular movement bilaterally. TMS intact and pearly gray bilaterally. Nasal and oral mucosa pink and moist, no ulceration. Intact dentition.
•    Neck: No edema or lymphadenopathy. smooth thyroid, no swelling or lumps. No skin discoloration.
•    Respiratory: Lungs clear to auscultation bilaterally. No masses on chest.Chest is symmetrical with respiration.
•    Cardiovascular: S1, S2, no rubs, gallops, or murmurs. Regular heart rate and rhythm. Capillary refill less than 3sec, No JVD.
•    Gastrointestinal:symmetric, soft, non-distended abdomen, no lesions or masses. Normoactive bowel sounds in all quadrants. No guarding, tenderness, or organomegaly. Case Studies Assignment Discussion Paper
•    Genitourinary: No edema or masses on the groin. Pubic hair well distributed. Normal external female genitalia. No rash, or vaginal bleeding or discharge.
•    Breasts: symmetrical breasts, no discreet or fixed mass. No discolored skin on breasts or nipples. No nipple discharge, axillary lymphadenopathy or dimpling.
•    Musculoskeletal: Full range of motion in all extremities bilaterally, 5/5 strength. Steady gait. No deformity.
•    Neurological: alert and oriented to person, place, time, and situation. Clear and coherent speech. Maintains good eye contact. Intact cranial nerve and cerebellar function. Intact memory and thought process.
•    Skin and Nails: Skin color congruent with ethnic background. Afebrile to touch. No jaundice or paleness. Intact, dry, warm and well nourished skin warm. No lesion, rash, or skin discoloration. Intact and well-trimmed nails, no discoloration.

 Diagnostics:

• CBC, cholesterol level test, hematocrit, and urinalysis results are all within normal limits. Case Studies Assignment Discussion Paper

Instructions Identify a friend, peer, or family member you can interview to collect complete and comprehensive subjective and objective data sets, as though they were a new patient in your office for an annual wellness visit. Conduct an interview and a physical exam. Document your findings in a Word file. Structure the subjective and objective data sets in the format provided in your lecture materials. Submit the Word file containing your data sets into Canvas. Estimated time to complete: 1.5 hours Rubric NU610 Unit 5 Assignment – Case Studies Rubric NU610 Unit 5 Assignment – Case Studies Rubric Criteria Ratings Pts This criterion is linked to a Learning Outcome Subjective Data 20 pts Highly Proficient Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are adeptly documented (all 9 elements are correctly documented) 16 pts Proficient Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are appropriately documented (at least 7 of the 9 elements are correctly documented) 12 pts Case Studies Assignment Discussion Paper

Marginally Proficient Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are satisfactorily documented (at least 5 of the 9 elements are correctly documented) 8 pts Approaching Proficiency Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are not satisfactorily documented (only 3 of the 9 elements are correctly documented) 4 pts Not Proficient Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are not satisfactorily documented (less than 3 of the 9 elements are correctly documented) 0 pts Not Evident An assignment submission is not located 20 pts This criterion is linked to a Learning Outcome Objective Data 20 pts Highly Proficient Elements of objective data are adeptly documented and demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS 16 pts Case Studies Assignment Discussion Paper

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Proficient Elements of objective data are appropriately documented and demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS 12 pts Marginally Proficient Elements of objective data are satisfactorily documented but do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS 8 pts Approaching Proficiency Elements of objective data are either not satisfactorily documented or do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS 4 pts Not Proficient Elements of objective data are not satisfactorily documented and do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS 0 pts Not Evident There are elements of objective data that are not provided in the assignment 20 pts Total Points: 40 Case Studies Assignment Discussion Paper