UNIT 6 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS, ROS, RELEVANT HISOTRY

Review the subjective and objective data sets provided in the 3 cases. You are to construct a subjective and objective data set for each case that demonstrates your knowledge of how to construct problem focused subjective and objective data sets.
Document your 3 subjective and objective data sets in a Word file.

UNIT 6 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS, ROS, RELEVANT HISOTRY, AND OBJECTIVE DATA INTO TYPHON FOR THREE FAMILY MEMBERS/FRIENDS

NU610 Unit 6 Case Studies

Case 1 – S.H

CHIEF COMPLAINT:

“I HAVE NO CURRENT CONCERNS; ROUTINE CHECK IN FOR BLOOD PRESSURE AND MEDICATION”

HISTORY OF PRESENT ILLNESS:

 (O)nset HYPERTENSION STARTED AT AGE 52  (L)ocation N/A  (D)uration N/A  (C)haracter N/A  (A)lleviating/Aggravating factors N/A  (R)aditation N/A  (T)ime N/A

Patient is a 61 year old female that presents today with no complaints. She is routinely seen to monitor her blood pressure and check blood pressure medications. She was diagnosed with hypertension at age 52, 9 years ago.

PAST MEDICAL HISTORY:

 Hypertension  Mild heart attack  Mild arthritis in bilateral hand  History of anxiety and depression  Bronchitis  Kidney stones

ALLERGIES:

 Seasonal allergies

CURRENT MEDICATIONS:

 Metoprolol  Ibuprofen

FAMILY HISTORY:

 Mother: hypertension, stroke at age 65, skin cancer removed from shoulder

UNIT 6 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS, ROS, RELEVANT HISOTRY, AND OBJECTIVE DATA INTO TYPHON FOR THREE FAMILY MEMBERS/FRIENDS

 Father: pasted away of Lou Gehrig’s disease at age 62  Maternal Grandmother: Unknown to patient  Maternal Grandfather: Unknown to patient  Paternal Grandmother: Died of old age  Paternal Grandfather: Heart disease, died of complications from heart disease

SOCIAL HISTORY:

 mother of 2  full-time job as accountant  Does not smoke cigarettes  Does not use illicit drugs  Drinks socially with friends once or twice a month

HEALTH PROMOTION:

 Patient due for Cholesterol, Hepatitis C, HIV/AIDS screening  Due for colonoscopy to screen for Colon Cancer  Immunizations are up to date  Patient had Pap and mammogram done last year

ROS:

General- Denies any weight changes recently. Appears well groomed. No reports of weakness, fatigue, or fever.

Skin- Denies rashes, lumps, sores, itching, dryness, or changes to color of skin. No changes to moles or nails. Hair is starting to turn gray.

HEENT- No report of headaches, dizziness, or light headedness. Patient wears glasses. Denies, pain redness, spots, flashing lights, tearing, glaucoma or cataracts. Denies issues with hearing, tinnitus, earaches, vertigo, or infection. Does not suffer from frequent colds, nasal stuffiness, itching, nosebleeds, or sinus trouble. Reports no problems with teeth or gums, dentures, or dry mouth. Denies frequent sore throats or hoarseness.

Neck- Denies any swollen glands, lumps, pain or stiffness in neck.

Breasts- Denies, lumps, pain, or discharge from breasts. Performs self-exam once a month.

Respiratory- Denies shortness of breath, cough, wheezing or pain. Patient states that she tends to get bronchitis easily in the winter is she develops a cold.

UNIT 6 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS, ROS, RELEVANT HISOTRY, AND OBJECTIVE DATA INTO TYPHON FOR THREE FAMILY MEMBERS/FRIENDS

Cardiovascular- Patient reports high blood pressure. States that a couple years ago she was under a lot of stress and reported having mild heart attack and has not had symptoms since. Denies chest pain or discomfort, murmurs, palpitations, shortness of breath, and swelling of extremities.

Gastrointestinal- Denies trouble swallowing, heartburn, nausea, or vomiting. No changes in appetite or bowel habits.

Peripheral vascular- Denies leg pain, cramps, clots, swelling or changes to color in extremities.

Urinary- Denies changes to urgency or frequency of urination. No recent blood or infection present. Patient has been treated for kidney stones in the past. Reports no incontinence.

Genital- Patient has completed two pregnancy and is menopausal

Musculoskeletal- Patient reports mild arthritis in hands. Denies all other joint pain, stiffness, gout, or backaches. Denies swelling, redness, pain, weakness, tenderness, or limitation to range of motion.

Psychiatric- Denies nervousness, mood, memory changes, suicidal ideations. Patient suffered depression when her father died and spoke with counselor at the time. Currently does not feel depressed.

Neurologic- Denies changes to mood, attention span, orientation, or speech. Reports no changes to memory or judgement. No headaches, dizziness, vertigo, or fainting.

Hematologic- Denies easily bruising or bleeding.

Endocrine- Denies excessive sweating, thirst or hunger. Reports no history of thyroid problems.

PHYSICAL EXAM:

General- Patient appears well groomed and dressed appropriately. Walks with normal gait and motor function. Patient is alert and orientated. Normal mood and affect.

Vital Signs- Blood pressure: 124/88, HR: 87, Resp: 16.

Skin- Appropriate moisture and temperature. Multiple freckles on face, arms. and legs. No apparent lesions. Inspection of hair is of normal texture and distribution. Nails are of normal color with no deformities. Patient is starting to grow grey hair. Nothing to note from palpation of scalp. Good turgor. No rashes or bruising.

UNIT 6 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS, ROS, RELEVANT HISOTRY, AND OBJECTIVE DATA INTO TYPHON FOR THREE FAMILY MEMBERS/FRIENDS

HEENT-

 Head – Normocephalic, no visual or palpable masses. Face and skull symmetrical.  Eyes – Eyes are in alignment. Conjunctiva clear. Sclera appears white. Pupils are

equal, round, and reactive bilaterally. Extraocular movements intact bilaterally. Patient wears glasses.

 Ears – Inspection of ear within normal limits. No problems with hearing bilaterally. (Do not have proper equipment to complete exam)

 Nose – Inspection of nasal mucosa, septum and turbinate within normal limits, no lesions or inflammation. No tenderness with palpation of maxillary and frontal sinuses.

 Throat – Inspection of oral mucosa, gums, teeth, tongue, palate, tonsils, lips, and pharynx within normal limits (pink, equal, aligned)

Neck- Inspection and palpation of cervical lymph nodes note no masses. No deviation in the trachea. No enlargement of thyroid noted.

Respiratory- Inspection and palpation symmetrical with no masses or abnormalities noted. Clear to auscultation and percussion.

Cardiovascular- Regular rate and rhythm, no murmurs, or gallops.

Gastrointestinal- Bowel sounds heard in all four quadrants. No tenderness with palpation. No mases or hernias noted.

Peripheral vascular- No edema some varicose veins noted on outer left thigh. Peripheral pulses intact.

Musculoskeletal- Normal gait. No tenderness, crepitation, masses, instability or decrease range of motion. Inspection is symmetrical. No atrophy or abnormal strength or tone.

Neurologic- Cranial nerves 2-12 intact/normal. Sensation to pain and touch is normal. Reflexes intact.

Case 2 – M.B

CHIEF COMPLAINT:

“I HAVE NO CURRENT CONCERNS”

HISTORY OF PRESENT ILLNESS:

 (O)nset N/A  (L)ocation N/A

UNIT 6 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS, ROS, RELEVANT HISOTRY, AND OBJECTIVE DATA INTO TYPHON FOR THREE FAMILY MEMBERS/FRIENDS

 (D)uration N/A  (C)haracter N/A  (A)lleviating/Aggravating factors N/A  (R)aditation N/A  (T)ime N/A

Patient is a 33 year old male that presents today with no complaints. Appears to be in good health.

PAST MEDICAL HISTORY:

 History of L4-L5 microdiscectomy

ALLERGIES:

 No known allergies

CURRENT MEDICATIONS:

 Ibuprofen on occasion

FAMILY HISTORY:

 Mother: healthy  Father: open heart surgery at age 67  Maternal Grandmother: Died of old age  Maternal Grandfather: Died of cancer (type unknown)  Paternal Grandmother: Died of old age  Paternal Grandfather: Died in motor vehicle accident

SOCIAL HISTORY:

 Married, Father of 2  full-time job as financial manager  Does not smoke cigarettes  Does not use illicit drugs  Drinks one to two beers nightly  Exercises by playing basketball three times weekly

HEALTH PROMOTION:

 Patient is due for blood pressure check  Denies need for HIV/AIDS screening as he has one sexual partner  Up to date on immunizations as he relies on health care provider records

UNIT 6 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS, ROS, RELEVANT HISOTRY, AND OBJECTIVE DATA INTO TYPHON FOR THREE FAMILY MEMBERS/FRIENDS

ROS:

General- Denies any weight changes recently. Appears well groomed. No reports of weakness, fatigue, or fever.

Skin- Denies rashes, lumps, sores, itching, dryness, or changes to color of skin. No changes to moles or nails. Hair is starting to turn gray in beard.

HEENT- No report of headaches, dizziness, or light headedness. Denies, pain redness, spots, flashing lights, tearing, glaucoma or cataracts. Denies issues with hearing, tinnitus, earaches, vertigo, or infection. Does not suffer from frequent colds, nasal stuffiness, itching, nosebleeds, or sinus trouble. Reports no problems with teeth or gums, dentures, or dry mouth. Denies frequent sore throats or hoarseness.

Neck- Denies any swollen glands, lumps, pain, or stiffness in neck.

Breasts- N/A

Respiratory- Denies shortness of breath, cough, wheezing or pain.

Cardiovascular- Denies chest pain or discomfort, murmurs, palpitations, shortness of breath, and swelling of extremities.

Gastrointestinal- Denies trouble swallowing, heartburn, nausea, or vomiting. No changes in appetite or bowel habits.

Peripheral vascular- Denies leg pain, cramps, clots, swelling or changes to color in extremities.

Urinary- Denies changes to urgency or frequency of urination. No recent blood or infection present. Reports no incontinence.

Genital- Reports no hernias, lumps, sores, pain, or discharge. Denies concern for STIs.

Musculoskeletal- Denies all other joint pain, stiffness, gout, or backaches. Denies swelling, redness, pain, weakness, tenderness, or limitation to range of motion. Reports preventative stretching daily for past lower back injury.

Psychiatric- Denies nervousness, mood, memory changes, suicidal ideations.

Neurologic- Denies changes to mood, attention span, orientation, or speech. Reports no changes to memory or judgement. No headaches, dizziness, vertigo, or fainting.

Hematologic- Denies easily bruising or bleeding.

UNIT 6 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS, ROS, RELEVANT HISOTRY, AND OBJECTIVE DATA INTO TYPHON FOR THREE FAMILY MEMBERS/FRIENDS

Endocrine- Denies excessive sweating, thirst, or hunger. Reports no history of thyroid problems.

PHYSICAL EXAM:

General- Patient appears well groomed and dressed appropriately. Walks with normal gait and motor function. Patient is alert and orientated. Normal mood and affect.

Vital Signs- Blood pressure: 118/68, HR: 70, Resp: 14.

Skin- Appropriate moisture and temperature. Patient has one lesion on back that is enlarged. Inspection of hair is of normal texture and distribution. Nails are of normal color with no deformities. Nothing to note from palpation of scalp. Good turgor. No rashes or bruising.

HEENT-

 Head – Normocephalic, no visual or palpable masses. Face and skull symmetrical.  Eyes – Eyes are in alignment. Conjunctiva clear. Sclera appears white. Pupils are

equal, round, and reactive bilaterally. Extraocular movements intact bilaterally.  Ears – Inspection of ear within normal limits. No problems with hearing

bilaterally. (Do not have proper equipment to complete exam)  Nose – Inspection of nasal mucosa, septum and turbinate within normal limits,

no lesions or inflammation. No tenderness with palpation of maxillary and frontal sinuses.

 Throat – Inspection of oral mucosa, gums, teeth, tongue, palate, tonsils, lips, and pharynx within normal limits (pink, equal, aligned)

Neck- Inspection and palpation of cervical lymph nodes note no masses. No deviation in the trachea. No enlargement of thyroid noted.

Respiratory- Inspection and palpation symmetrical with no masses or abnormalities noted. Clear to auscultation and percussion.

Cardiovascular- Regular rate and rhythm, no murmurs, or gallops.

Gastrointestinal- Bowel sounds heard in all four quadrants. No tenderness with palpation. No mases or hernias noted.

Peripheral vascular- No edema some varicose veins noted on outer left thigh. Peripheral pulses intact.

Musculoskeletal- Normal gait. No tenderness, crepitation, masses, instability or decrease range of motion. Inspection is symmetrical. No atrophy or abnormal strength or tone.

UNIT 6 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS, ROS, RELEVANT HISOTRY, AND OBJECTIVE DATA INTO TYPHON FOR THREE FAMILY MEMBERS/FRIENDS

Neurologic- Cranial nerves 2-12 intact/normal. Sensation to pain and touch is normal. Reflexes intact.

Case 3 – S.T

CHIEF COMPLAINT:

“I CURRENTLY HAVE NO CONCERNS”

HISTORY OF PRESENT ILLNESS:

 (O)nset N/A  (L)ocation N/A  (D)uration N/A  (C)haracter N/A  (A)lleviating/Aggravating factors N/A  (R)aditation N/A  (T)ime N/A

Patient is a 30 year old female that presents today with no complaints. Appears in relatively good heath and shape.

PAST MEDICAL HISTORY:

 History of kidney infections  Wisdom teeth out at age 17  History of starched corona  Vitiligo

ALLERGIES:

 Tree Nuts

CURRENT MEDICATIONS:

 Ibuprofen – rarely  Marana

FAMILY HISTORY:

 Mother: hypertension, kidney stones, history of depression  Father: open heart surgery in 2009 and 2020, pre-diabetic  Maternal Grandmother: stroke at 65, skin cancer on shoulder-surgically removed

UNIT 6 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS, ROS, RELEVANT HISOTRY, AND OBJECTIVE DATA INTO TYPHON FOR THREE FAMILY MEMBERS/FRIENDS

 Maternal Grandfather: pasted away of Lou Gehrig’s disease at age 62  Paternal Grandmother: Heart disease, died of heart related complications  Paternal Grandfather: Heart disease, hypertension, died of heart attack

SOCIAL HISTORY:

 full-time job as manager of operations  Does not smoke cigarettes  Does not use illicit drugs  Drinks socially with friends once a week  Runs daily for exercise  Married  No children

HEALTH PROMOTION:

 Patient is due for blood pressure check  Denies need for HIV/AIDS screening as she has one sexual partner  Up to date on immunizations  Had Pap smear earlier this year

ROS:

General- Denies any weight changes recently. Appears well groomed. No reports of weakness, fatigue, or fever.

Skin- Denies rashes, lumps, sores, itching, dryness. Changes to color of skin as it gets lighter. No changes to moles or nails. Reports no changes with hair.

HEENT- No report of headaches, dizziness, or light headedness. Patient wears glasses. Denies, pain redness, spots, flashing lights, tearing, glaucoma or cataracts. Denies issues with hearing, tinnitus, earaches, vertigo, or infection. Does not suffer from frequent colds, nasal stuffiness, itching, nosebleeds, or sinus trouble. Reports no problems with teeth or gums, dentures, or dry mouth. Denies frequent sore throats or hoarseness.

Neck- Denies any swollen glands, lumps, pain, or stiffness in neck.

Breasts- Denies, lumps, pain, or discharge from breasts. Performs self-exam once a month.

Respiratory- Denies shortness of breath, cough, wheezing or pain. Patient states that she tends to get bronchitis easily in the winter is she develops a cold.

UNIT 6 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS, ROS, RELEVANT HISOTRY, AND OBJECTIVE DATA INTO TYPHON FOR THREE FAMILY MEMBERS/FRIENDS

Cardiovascular- Patient reports high blood pressure. States that a couple years ago she was under a lot of stress and reported having mild heart attack and has not had symptoms since. Denies chest pain or discomfort, murmurs, palpitations, shortness of breath, and swelling of extremities.

Gastrointestinal- Denies trouble swallowing, heartburn, nausea, or vomiting. No changes in appetite or bowel habits.

Peripheral vascular- Denies leg pain, cramps, clots, swelling or changes to color in extremities.

Urinary- Denies changes to urgency or frequency of urination. No recent blood or infection present. Patient has been treated for kidney stones in the past. Reports no incontinence. Has not had a kidney infection for ten plus years.

Genital- Patient Denies concern for STIs. Does not get period with Marana.

Musculoskeletal- Denies all other joint pain, stiffness, gout, or backaches. Denies swelling, redness, pain, weakness, tenderness, or limitation to range of motion.

Psychiatric- Denies nervousness, mood, memory changes, suicidal ideations.

Neurologic- Denies changes to mood, attention span, orientation, or speech. Reports no changes to memory or judgement. No headaches, dizziness, vertigo, or fainting.

Hematologic- Denies easily bruising or bleeding.

Endocrine- Denies excessive sweating, thirst, or hunger. Reports no history of thyroid problems.

PHYSICAL EXAM:

General- Patient appears well groomed and dressed appropriately. Walks with normal gait and motor function. Patient is alert and orientated. Normal mood and affect.

Vital Signs- Blood pressure: 120/76, HR: 78, Resp: 16.

Skin- Appropriate moisture and temperature. No apparent lesions. Inspection of hair is of normal texture and distribution. Nails are of normal color with no deformities. Nothing to note from palpation of scalp. Good turgor. No rashes or bruising.

HEENT-

UNIT 6 ASSIGNMENT ENTER CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS, ROS, RELEVANT HISOTRY, AND OBJECTIVE DATA INTO TYPHON FOR THREE FAMILY MEMBERS/FRIENDS

 Head – Normocephalic, no visual or palpable masses. Face and skull symmetrical.  Eyes – Eyes are in alignment. Conjunctiva clear. Sclera appears white. Pupils are

equal, round, and reactive bilaterally. Extraocular movements intact bilaterally. Patient has contacts placed.

 Ears – Inspection of ear within normal limits. No problems with hearing bilaterally. (Do not have proper equipment to complete exam)

 Nose – Inspection of nasal mucosa, septum and turbinate within normal limits, no lesions or inflammation. No tenderness with palpation of maxillary and frontal sinuses.

 Throat – Inspection of oral mucosa, gums, teeth, tongue, palate, tonsils, lips, and pharynx within normal limits (pink, equal, aligned)

Neck- Inspection and palpation of cervical lymph nodes note no masses. No deviation in the trachea. No enlargement of thyroid noted.

Respiratory- Inspection and palpation symmetrical with no masses or abnormalities noted. Clear to auscultation and percussion.

Cardiovascular- Regular rate and rhythm, no murmurs, or gallops.

Gastrointestinal- Bowel sounds heard in all four quadrants. No tenderness with palpation. No mases or hernias noted.

Peripheral vascular- No edema some varicose veins noted on outer left thigh. Peripheral pulses intact.

Musculoskeletal- Normal gait. No tenderness, crepitation, masses, instability or decrease range of motion. Inspection is symmetrical. No atrophy or abnormal strength or tone.

Neurologic- Cranial nerves 2-12 intact/normal. Sensation to pain and touch is normal. Reflexes intact.

Document your focused respiratory assessment for Vincent Brody.