CASE STUDY 5

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Home>Homework Answsers>Nursing homework helpCOMPREHENSIVE CASE STUDY – CHIEF COMPLAINT – SHOULDER PAIN9 months ago30.11.202425Report issuefiles (2)CASESTUDY5OBUM.docxROS_Template_2023.docxCASESTUDY5OBUM.docxCOMPREHENSIVE CASE STUDY – CHIEF COMPLAINT – SHOULDER PAINHistory of Present IllnessA 26-year-old male firefighter presents to his PCP following an ED visit for an episode of dehydration and severe muscle pain experienced during rigorous physical activity. Yesterday, he fought a fire for an extended period under extreme physical conditions. Despite consuming significant amounts of water, he began feeling lightheaded, experienced severe pain in his calves and shoulders, and noticed dark-colored urine. He was evaluated in the ED and discharged with instructions to hydrate. However, he continues to have dark-colored urine, generalized muscle pain, and fatigue. He reports feeling “like I’ve been hit by a truck.”Review of Systems (ROS)Positive:Weakness, exhaustion, palpitations, shortness of breath, nausea, dark-colored urine, muscle pain (shoulders, lower back, calves).Negative:Diarrhea, constipation, anuria, hematuria, muscle weakness, numbness, tingling.Past Medical History:Recurrent musculoskeletal injuries (shoulder, knee), HTN, and anxiety.Social History:Moderate alcohol use (occasional beer), no tobacco or drug use. Unmarried in a casual relationship with no children. Active lifestyleFamily History:Mother with breast cancer (remission), father without chronic conditions. Sibling brother with Hx chronic migrainesAllergies:None.Medications:Ibuprofen 200mg PO q 8 hrs PRN muscle aches, Lisinopril 2.5mg PO daily, Lexapro 10mg PO daily.Physical ExaminationVitals:T 37.3°C (99.1°F), P 96BPM, RR 12 BPM, BP 134/86, BMI 29.7.General:A&O; no acute distress; overweight.Skin:No erythema, pallor, or abnormalities noted.HEENT:Normal findings.Lungs:Vesicular breath sounds throughout, equal bilaterally.Cardiac:Regular rate and rhythm, no murmurs/rubs/gallops.Abdomen:Soft, mild epigastric tenderness, bilateral flank tenderness, no CVA tenderness.Musculoskeletal:Tenderness over bilateral shoulders, reduced ROM due to pain, generalized tenderness of calves and quadriceps, severe paralumbar tenderness with guarding and hypertonicity.Neurological:A&O×3; cranial nerves intact.CLINICAL DISCUSSIONBased on the subjective and objective information presented,select and prioritize threedifferential diagnoses, including each diagnosis’s rationale,pathophysiology, and pertinent positives and negatives.For the working diagnosis, explain why this is the primary diagnosis, what physical findings support the primary diagnosis, and list any additional body systems not addressed in the physical exam and how those physical findings could further support your primary diagnosis.·  List any additional questions you may have inquired about in your history taking that have not already been presented in the HPI and are necessary to establish your diagnosis.· Address any necessary laboratory or diagnostic testing and the clinical significance of these diagnostics for your diagnosis or ultimate treatment plan.· Discuss the next appropriate steps in your management and at leasttwo potential complications of this diagnosis untreated.· Finally, discuss medication management, including pharmacologic and nonpharmacologic choices with appropriate dosing, comprehensive patient education, and follow-up recommendations.Recall the necessary components in your case studies from NUR631. We will continue to build on the format throughout the clinical aspect of adulthood.APA format with at least FIVE peer-reviewed references to support diagnosis, management, and patient education.APA FORMAT, AND REFERENCES, peer review scholarly resource cited in APA format from 2019-2024 only. (Within the last five years)Please do not solely use a website as your scholarly reference. While it is fine to use it as a supplement, a journal article or text should be referenced.Please use North American peer-reviewed journals,DO NOT use any European JournalPlease use reliable medical references such as the Current Medical Diagnosis and Treatment book or UpToDate. Do not use WebMD, Wikipedia, etc., as these are not advanced practice references.APA format (if using outside sources).CriterionExemplary (Full Points)ProficientSatisfactoryNeeds ImprovementUnsatisfactoryDifferential Diagnosis Development and Justification (30 Points)30–26 Points: Identifies three well-prioritized differential diagnoses with clear and accurate rationale. Pathophysiology is detailed and evidence-based. Pertinent positives and negatives are comprehensive and clearly linked to the clinical presentation.25–21 Points: Identifies three differential diagnoses with adequate rationale and pathophysiology. Pertinent positives and negatives are mostly accurate but may lack depth or clarity.20–16 Points: Identifies three differential diagnoses but with limited rationale or incomplete pathophysiology. Pertinent findings are minimally addressed or lack depth.15–11 Points: Fewer than three differential diagnoses, or rationale and pathophysiology are unclear or incorrect. Pertinent findings are not fully addressed.10–0 Points: Little to no effort to develop differential diagnoses, rationale, or supporting findings.Working Diagnosis and Supporting Evidence (20 Points)20–18 Points: Working diagnosis is logically prioritized and strongly supported with clinical evidence. Additional body systems and findings are identified and well-justified.17–15 Points: Working diagnosis is clearly identified and supported by evidence, though explanation of additional systems or findings may lack depth or specificity.14–12 Points: Working diagnosis is identified but lacks a thorough explanation or fails to integrate key clinical evidence. Additional systems are mentioned but minimally explained.11–8 Points: Working diagnosis is unclear or poorly supported by clinical evidence. Additional systems are not addressed or lack rationale.7–0 Points: Working diagnosis is absent or unsupported by clinical reasoning.History, Diagnostic Testing, and Relevance (20 Points)20–18 Points: Comprehensive history questions are identified, relevant to the case, and explained thoroughly. Diagnostic testing choices are appropriate and well-rationalized, with clear connections to the diagnosis and management.17–15 Points: History questions and diagnostics are mostly appropriate and relevant, though some explanations or connections to the case may be incomplete.14–12 Points: History and diagnostics are partially appropriate but lack depth or connection to the diagnosis and management.11–8 Points: History and diagnostics are incomplete or minimally relevant, with little explanation of their significance.7–0 Points: Few or no relevant history questions or diagnostic tests are identified.Management Plan and Complications (20 Points)20–18 Points: Comprehensive management plan includes pharmacologic and non-pharmacologic treatments with appropriate dosing and monitoring. Potential complications of untreated diagnosis are well-described and clinically relevant.17–15 Points: Management plan addresses most key elements but may lack depth or specificity in treatment choices or complication discussion.14–12 Points: Management plan includes some key elements but lacks clarity or thoroughness in treatment options or addressing complications.11–8 Points: Management plan is incomplete or poorly justified. Complications are minimally addressed or not relevant.7–0 Points: Management plan is absent or not relevant to the case.Patient Education and Follow-Up (10 Points)10 Points: Comprehensive patient education addresses lifestyle changes, medication use, and symptom monitoring. Follow-up recommendations are detailed and appropriately prioritized.9–8 Points: Patient education and follow-up are thorough, though some aspects of lifestyle or symptom management may lack detail.7–6 Points: Patient education and follow-up are included but lack depth or specificity in addressing lifestyle or treatment adherence.RubricROS_Template_2023.docx-GeneralUsual weight, recent weight change, weakness, fatigue, or fever-SkinRashes, lumps, sores, itching, dryness, changes in color, changes in hair or nails, changes in size or color moles-Head, Eyes, Ears, Nose, Throat (HEENT):-Head: Headache, head injury, dizziness, lightheadedness.Eyes: Vision, glasses or contact lenses, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts.Ears: Hearing, Tinnitus, Vertigo, earaches, infection, discharge, If hearing is decreased, use or nonuse of hearing aids,Nose and Sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nose- bleeds, sinus trouble.Throat(or mouth and Pharynx): Condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, sore tongue, dry mouth, frequent sore throats, hoarseness.-Neck“Swollen Glands,” goiter, lumps, pain, or stiffness in the neck.-BreastLumps, pain, or discomfort, nipple discharge-RespiratoryCough, sputum (color quantity; presence of blood or hemoptysis), shortness of breath (dyspnea), wheezing, pain with a deep breath (Pleuritic pain).-Cardiovascular“Heart trouble”; high blood pressure; rheumatic fever; heath murmurs; chest pain or discomfort; palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea); need to sit up at night to ease breathing (paroxysmal nocturnal dyspnea) swelling in the hands , ankles, or feet (edema).-GastrointestinalTrouble swallowing, heartburn, appetite, nausea. Bowel movements, stool color and size, change bowel habits, pain constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver, or gallbladder trouble.-Peripheral VascularIntermittent leg pain with exertion (Claudication); leg cramps; varicose veins; past clots in the veins; past clots in the veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness.-UrinaryFrequency or urination,  polyuria, nighttime urination (nocturia), urgency, burning or pain during urination, blood in the urine (hematuria), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence;  in males, reduced caliber or force of the urinary stream, hesitancy, dribbling.-GenitalMale:Hernia, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infection and their treatments. Sexual interest (Libido), function, satisfactionFemale:Menstrual regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, dysmenorrhea, premenstrual tension. Menopausal symptoms, post-menopausal bleeding. Vaginal discharge, itching, sores, lumps, sexually transmitted infection, and treatments. Sexual interest, satisfaction, any problems, including pain during intercourse (dyspareunia)-MusculoskeletalMuscle or joint pain, stiffness, arthritis, gout, backache. If present, describe the location of affected joints or muscles, any swelling, redness, pain , tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness.-PsychiatricNervousness, tension, mood, including depression, memory change, suicidal ideation, suicide plans or attempts.-NeurologicChanges in mood, attention, or speech;  changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis, numbness, loss of sensation, tingling or “pins and needles,” tremors or other involuntary movement seizures.-HematologicAnemia, easy bruising, or bleeding-EndocrineHeat or cold intolerance, excessive sweating ,excessive thirst (polydipsia), hunger (polyphagia), or urine output (polyuria).-Physical ExaminationGeneral Survey:MN is a short, overweight middle-aged female, who is animated and responds quickly  to questions. Her hair was well groomed. Her color is good, and she lies flat.Vital Signs:Ht(without shoes) 157 cm (5’2”). Wt (dressed) 65 kg (143 lbs) . BMI 26, BP 164/98 right arm supine; 160/96 left arm, supine; 152/88 right arm, supine with wide cuff. Heart rate (HR) 88 and regular. Respiratory rate (RR) 18. Temperature (oral) 98.6F.Skin:Palms cold and moist, but color good. Scattered Cherry angiomas over upper trunk. Nails without clubbing , cyanosis.Head, Eyes, Ears, Nose, Throat (HEENT): Head;hair of average texture, Scalp without lesions, normocephalic/ atraumatic (NC?AT).Eyes;Vision 20/30 in each eye.Visual fields full by confrontation. Conjunctive pink; sclera white. Pupils 4 mm constricting to 2 mm, round, regular, equally reactive to light. Extraocular movements intact. Disc margins sharp, without hemorrhage, exudate. No arteriolar narrowing or A-V nicking.Ears:Cerumen partially obscures right tympanic membrane (™); Left canal clear, ™ with good cone of light. Acuity is a good to whispered voice. Weber midline. AC>BC.NoseMucosa pink, septum midline. No sinus tenderness.Mouth:Oral mucosa pink. Dentition is good. Tongue midline. Tonsils absent. Pharynx without exudates.Neck:Neck Supple. Trachea midline. Thyroid isthmus barely palpable, lobes not felt.Lymph Nodes:No cervical, axillary, or epitrochlear nodes.Thorax and Lungs:Thorax Symmetric with good excursion. Lungs resonant on percussion. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.Cardiovascular:Jugular venous pressure 1 cm above the sternal angle, with the head of the examining table raised to 30 degrees. Carotid upstrokes brisk, without bruits. Apical impulse discrete and tapping, barely palpable in the 5th left interspace, 8 cm lateral to the midsternal line. Good S1,,.S2,: no S3 or S3,. A II/VI medium-pitched midsystolic murmur at the 2nd right interspace; does not radiate to the neck. No diastolic murmurs.Breast:pendulous, symmetric.. No masses; nipples without discharge.Abdomen:Protuberant. Well-healed scar, right lower quadrant. Bowelsounds active. No tenderness or masses. Liver span 7cm  in right midclavicular line; edge smooth, palpable 1 cm below right costal margin (RCM). Spleen not felt. No costovertebral angles tenderness (CVAT).Genitalia:FemaleExternal genitalia without lesions. Mild cystocele at introitus on straining. Vaginal mucosa pink. Cervix pink, parous, and without discharge. Uterus anterior, midline, smooth, not enlarged . Adnexa is not palpated due to obesity and poor relaxation. No cervical or Adnexal tenderness. Pap Smear taken. Rectovaginal wall intact.MaleExternal genitalia without discharge or lesions. No scrotal or testicular mases or swelling, no hernia.Rectal:No external hemorrhoids, tight sphincter tone, rectal vault without masses, stool brown negative for occult blood.Extremities:Bilateral upper extremities warm. Bilateral lower extremities; no edema. Calves supple, symmetric, temperature intact bilaterally with negative Homan’s sign.Peripheral vascular:No varicosities in lower extremities. No stasis pigmentation or ulcers Pulses. (2+ = normal)_________________________________________________________Radial           Femoral      Popliteal       Dorsalis Pedis    Posterior Tibial_________________________________________________________Rt 2+ 2+ 2+ 2+ 2+_______________________________________________________Lt 2+ 2+ 2+ 2+ 2+Musculoskeletal:No joint deformities or selling on inspection and palpation. Good range of motion in hands, wrists, elbows, shoulders, spine, hips, knees, ankles.Neurologic: Mental Status:Alert and cooperative. Thought processes are coherent and insight is good. Oriented to person, place, and time. Cranialnerves:II to XII intact.Motor:Good muscle bulk and tone.Strength:5/5 bilaterally in deltoids, biceps, triceps, hand grips, iliopsoas, hamstrings, quadriceps, tibialis anterior, and gastrocnemius.Cerebellar:Rapid Alternating movements (RAMs)  and point-to-point movements intact. Gait stable, fluid.Sensory:Pinprick, light touch, position sense, vibration, and stereognosis intact. Romberg negative.Reflexes:Bilateral triceps, brachioradialis, patellar and Achilles deep tendon reflexes intact. Bilateral plantar reflex intact. Babinski response is negative.ROS_Template_2023.docx-GeneralUsual weight, recent weight change, weakness, fatigue, or fever-SkinRashes, lumps, sores, itching, dryness, changes in color, changes in hair or nails, changes in size or color moles-Head, Eyes, Ears, Nose, Throat (HEENT):-Head: Headache, head injury, dizziness, lightheadedness.Eyes: Vision, glasses or contact lenses, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts.Ears: Hearing, Tinnitus, Vertigo, earaches, infection, discharge, If hearing is decreased, use or nonuse of hearing aids,Nose and Sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nose- bleeds, sinus trouble.Throat(or mouth and Pharynx): Condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, sore tongue, dry mouth, frequent sore throats, hoarseness.-Neck“Swollen Glands,” goiter, lumps, pain, or stiffness in the neck.-BreastLumps, pain, or discomfort, nipple discharge-RespiratoryCough, sputum (color quantity; presence of blood or hemoptysis), shortness of breath (dyspnea), wheezing, pain with a deep breath (Pleuritic pain).-Cardiovascular“Heart trouble”; high blood pressure; rheumatic fever; heath murmurs; chest pain or discomfort; palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea); need to sit up at night to ease breathing (paroxysmal nocturnal dyspnea) swelling in the hands , ankles, or feet (edema).-GastrointestinalTrouble swallowing, heartburn, appetite, nausea. Bowel movements, stool color and size, change bowel habits, pain constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver, or gallbladder trouble.-Peripheral VascularIntermittent leg pain with exertion (Claudication); leg cramps; varicose veins; past clots in the veins; past clots in the veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness.-UrinaryFrequency or urination,  polyuria, nighttime urination (nocturia), urgency, burning or pain during urination, blood in the urine (hematuria), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence;  in males, reduced caliber or force of the urinary stream, hesitancy, dribbling.-GenitalMale:Hernia, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infection and their treatments. Sexual interest (Libido), function, satisfactionFemale:Menstrual regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, dysmenorrhea, premenstrual tension. Menopausal symptoms, post-menopausal bleeding. Vaginal discharge, itching, sores, lumps, sexually transmitted infection, and treatments. Sexual interest, satisfaction, any problems, including pain during intercourse (dyspareunia)-MusculoskeletalMuscle or joint pain, stiffness, arthritis, gout, backache. If present, describe the location of affected joints or muscles, any swelling, redness, pain , tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness.-PsychiatricNervousness, tension, mood, including depression, memory change, suicidal ideation, suicide plans or attempts.-NeurologicChanges in mood, attention, or speech;  changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis, numbness, loss of sensation, tingling or “pins and needles,” tremors or other involuntary movement seizures.-HematologicAnemia, easy bruising, or bleeding-EndocrineHeat or cold intolerance, excessive sweating ,excessive thirst (polydipsia), hunger (polyphagia), or urine output (polyuria).-Physical ExaminationGeneral Survey:MN is a short, overweight middle-aged female, who is animated and responds quickly  to questions. Her hair was well groomed. Her color is good, and she lies flat.Vital Signs:Ht(without shoes) 157 cm (5’2”). Wt (dressed) 65 kg (143 lbs) . BMI 26, BP 164/98 right arm supine; 160/96 left arm, supine; 152/88 right arm, supine with wide cuff. Heart rate (HR) 88 and regular. Respiratory rate (RR) 18. Temperature (oral) 98.6F.Skin:Palms cold and moist, but color good. Scattered Cherry angiomas over upper trunk. Nails without clubbing , cyanosis.Head, Eyes, Ears, Nose, Throat (HEENT): Head;hair of average texture, Scalp without lesions, normocephalic/ atraumatic (NC?AT).Eyes;Vision 20/30 in each eye.Visual fields full by confrontation. Conjunctive pink; sclera white. Pupils 4 mm constricting to 2 mm, round, regular, equally reactive to light. Extraocular movements intact. Disc margins sharp, without hemorrhage, exudate. No arteriolar narrowing or A-V nicking.Ears:Cerumen partially obscures right tympanic membrane (™); Left canal clear, ™ with good cone of light. Acuity is a good to whispered voice. Weber midline. AC>BC.NoseMucosa pink, septum midline. No sinus tenderness.Mouth:Oral mucosa pink. Dentition is good. Tongue midline. Tonsils absent. Pharynx without exudates.Neck:Neck Supple. Trachea midline. Thyroid isthmus barely palpable, lobes not felt.Lymph Nodes:No cervical, axillary, or epitrochlear nodes.Thorax and Lungs:Thorax Symmetric with good excursion. Lungs resonant on percussion. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.Cardiovascular:Jugular venous pressure 1 cm above the sternal angle, with the head of the examining table raised to 30 degrees. Carotid upstrokes brisk, without bruits. Apical impulse discrete and tapping, barely palpable in the 5th left interspace, 8 cm lateral to the midsternal line. Good S1,,.S2,: no S3 or S3,. A II/VI medium-pitched midsystolic murmur at the 2nd right interspace; does not radiate to the neck. No diastolic murmurs.Breast:pendulous, symmetric.. No masses; nipples without discharge.Abdomen:Protuberant. Well-healed scar, right lower quadrant. Bowelsounds active. No tenderness or masses. Liver span 7cm  in right midclavicular line; edge smooth, palpable 1 cm below right costal margin (RCM). Spleen not felt. No costovertebral angles tenderness (CVAT).Genitalia:FemaleExternal genitalia without lesions. Mild cystocele at introitus on straining. Vaginal mucosa pink. Cervix pink, parous, and without discharge. Uterus anterior, midline, smooth, not enlarged . Adnexa is not palpated due to obesity and poor relaxation. No cervical or Adnexal tenderness. Pap Smear taken. Rectovaginal wall intact.MaleExternal genitalia without discharge or lesions. No scrotal or testicular mases or swelling, no hernia.Rectal:No external hemorrhoids, tight sphincter tone, rectal vault without masses, stool brown negative for occult blood.Extremities:Bilateral upper extremities warm. Bilateral lower extremities; no edema. Calves supple, symmetric, temperature intact bilaterally with negative Homan’s sign.Peripheral vascular:No varicosities in lower extremities. No stasis pigmentation or ulcers Pulses. (2+ = normal)_________________________________________________________Radial           Femoral      Popliteal       Dorsalis Pedis    Posterior Tibial_________________________________________________________Rt 2+ 2+ 2+ 2+ 2+_______________________________________________________Lt 2+ 2+ 2+ 2+ 2+Musculoskeletal:No joint deformities or selling on inspection and palpation. Good range of motion in hands, wrists, elbows, shoulders, spine, hips, knees, ankles.Neurologic: Mental Status:Alert and cooperative. Thought processes are coherent and insight is good. Oriented to person, place, and time. Cranialnerves:II to XII intact.Motor:Good muscle bulk and tone.Strength:5/5 bilaterally in deltoids, biceps, triceps, hand grips, iliopsoas, hamstrings, quadriceps, tibialis anterior, and gastrocnemius.Cerebellar:Rapid Alternating movements (RAMs)  and point-to-point movements intact. Gait stable, fluid.Sensory:Pinprick, light touch, position sense, vibration, and stereognosis intact. Romberg negative.Reflexes:Bilateral triceps, brachioradialis, patellar and Achilles deep tendon reflexes intact. Bilateral plantar reflex intact. Babinski response is negative.CASESTUDY5OBUM.docxCOMPREHENSIVE CASE STUDY – CHIEF COMPLAINT – SHOULDER PAINHistory of Present IllnessA 26-year-old male firefighter presents to his PCP following an ED visit for an episode of dehydration and severe muscle pain experienced during rigorous physical activity. Yesterday, he fought a fire for an extended period under extreme physical conditions. Despite consuming significant amounts of water, he began feeling lightheaded, experienced severe pain in his calves and shoulders, and noticed dark-colored urine. He was evaluated in the ED and discharged with instructions to hydrate. However, he continues to have dark-colored urine, generalized muscle pain, and fatigue. He reports feeling “like I’ve been hit by a truck.”Review of Systems (ROS)Positive:Weakness, exhaustion, palpitations, shortness of breath, nausea, dark-colored urine, muscle pain (shoulders, lower back, calves).Negative:Diarrhea, constipation, anuria, hematuria, muscle weakness, numbness, tingling.Past Medical History:Recurrent musculoskeletal injuries (shoulder, knee), HTN, and anxiety.Social History:Moderate alcohol use (occasional beer), no tobacco or drug use. Unmarried in a casual relationship with no children. Active lifestyleFamily History:Mother with breast cancer (remission), father without chronic conditions. Sibling brother with Hx chronic migrainesAllergies:None.Medications:Ibuprofen 200mg PO q 8 hrs PRN muscle aches, Lisinopril 2.5mg PO daily, Lexapro 10mg PO daily.Physical ExaminationVitals:T 37.3°C (99.1°F), P 96BPM, RR 12 BPM, BP 134/86, BMI 29.7.General:A&O; no acute distress; overweight.Skin:No erythema, pallor, or abnormalities noted.HEENT:Normal findings.Lungs:Vesicular breath sounds throughout, equal bilaterally.Cardiac:Regular rate and rhythm, no murmurs/rubs/gallops.Abdomen:Soft, mild epigastric tenderness, bilateral flank tenderness, no CVA tenderness.Musculoskeletal:Tenderness over bilateral shoulders, reduced ROM due to pain, generalized tenderness of calves and quadriceps, severe paralumbar tenderness with guarding and hypertonicity.Neurological:A&O×3; cranial nerves intact.CLINICAL DISCUSSIONBased on the subjective and objective information presented,select and prioritize threedifferential diagnoses, including each diagnosis’s rationale,pathophysiology, and pertinent positives and negatives.For the working diagnosis, explain why this is the primary diagnosis, what physical findings support the primary diagnosis, and list any additional body systems not addressed in the physical exam and how those physical findings could further support your primary diagnosis.·  List any additional questions you may have inquired about in your history taking that have not already been presented in the HPI and are necessary to establish your diagnosis.· Address any necessary laboratory or diagnostic testing and the clinical significance of these diagnostics for your diagnosis or ultimate treatment plan.· Discuss the next appropriate steps in your management and at leasttwo potential complications of this diagnosis untreated.· Finally, discuss medication management, including pharmacologic and nonpharmacologic choices with appropriate dosing, comprehensive patient education, and follow-up recommendations.Recall the necessary components in your case studies from NUR631. We will continue to build on the format throughout the clinical aspect of adulthood.APA format with at least FIVE peer-reviewed references to support diagnosis, management, and patient education.APA FORMAT, AND REFERENCES, peer review scholarly resource cited in APA format from 2019-2024 only. (Within the last five years)Please do not solely use a website as your scholarly reference. While it is fine to use it as a supplement, a journal article or text should be referenced.Please use North American peer-reviewed journals,DO NOT use any European JournalPlease use reliable medical references such as the Current Medical Diagnosis and Treatment book or UpToDate. Do not use WebMD, Wikipedia, etc., as these are not advanced practice references.APA format (if using outside sources).CriterionExemplary (Full Points)ProficientSatisfactoryNeeds ImprovementUnsatisfactoryDifferential Diagnosis Development and Justification (30 Points)30–26 Points: Identifies three well-prioritized differential diagnoses with clear and accurate rationale. Pathophysiology is detailed and evidence-based. Pertinent positives and negatives are comprehensive and clearly linked to the clinical presentation.25–21 Points: Identifies three differential diagnoses with adequate rationale and pathophysiology. Pertinent positives and negatives are mostly accurate but may lack depth or clarity.20–16 Points: Identifies three differential diagnoses but with limited rationale or incomplete pathophysiology. Pertinent findings are minimally addressed or lack depth.15–11 Points: Fewer than three differential diagnoses, or rationale and pathophysiology are unclear or incorrect. Pertinent findings are not fully addressed.10–0 Points: Little to no effort to develop differential diagnoses, rationale, or supporting findings.Working Diagnosis and Supporting Evidence (20 Points)20–18 Points: Working diagnosis is logically prioritized and strongly supported with clinical evidence. Additional body systems and findings are identified and well-justified.17–15 Points: Working diagnosis is clearly identified and supported by evidence, though explanation of additional systems or findings may lack depth or specificity.14–12 Points: Working diagnosis is identified but lacks a thorough explanation or fails to integrate key clinical evidence. Additional systems are mentioned but minimally explained.11–8 Points: Working diagnosis is unclear or poorly supported by clinical evidence. Additional systems are not addressed or lack rationale.7–0 Points: Working diagnosis is absent or unsupported by clinical reasoning.History, Diagnostic Testing, and Relevance (20 Points)20–18 Points: Comprehensive history questions are identified, relevant to the case, and explained thoroughly. Diagnostic testing choices are appropriate and well-rationalized, with clear connections to the diagnosis and management.17–15 Points: History questions and diagnostics are mostly appropriate and relevant, though some explanations or connections to the case may be incomplete.14–12 Points: History and diagnostics are partially appropriate but lack depth or connection to the diagnosis and management.11–8 Points: History and diagnostics are incomplete or minimally relevant, with little explanation of their significance.7–0 Points: Few or no relevant history questions or diagnostic tests are identified.Management Plan and Complications (20 Points)20–18 Points: Comprehensive management plan includes pharmacologic and non-pharmacologic treatments with appropriate dosing and monitoring. Potential complications of untreated diagnosis are well-described and clinically relevant.17–15 Points: Management plan addresses most key elements but may lack depth or specificity in treatment choices or complication discussion.14–12 Points: Management plan includes some key elements but lacks clarity or thoroughness in treatment options or addressing complications.11–8 Points: Management plan is incomplete or poorly justified. Complications are minimally addressed or not relevant.7–0 Points: Management plan is absent or not relevant to the case.Patient Education and Follow-Up (10 Points)10 Points: Comprehensive patient education addresses lifestyle changes, medication use, and symptom monitoring. Follow-up recommendations are detailed and appropriately prioritized.9–8 Points: Patient education and follow-up are thorough, though some aspects of lifestyle or symptom management may lack detail.7–6 Points: Patient education and follow-up are included but lack depth or specificity in addressing lifestyle or treatment adherence.RubricROS_Template_2023.docx-GeneralUsual weight, recent weight change, weakness, fatigue, or fever-SkinRashes, lumps, sores, itching, dryness, changes in color, changes in hair or nails, changes in size or color moles-Head, Eyes, Ears, Nose, Throat (HEENT):-Head: Headache, head injury, dizziness, lightheadedness.Eyes: Vision, glasses or contact lenses, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts.Ears: Hearing, Tinnitus, Vertigo, earaches, infection, discharge, If hearing is decreased, use or nonuse of hearing aids,Nose and Sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nose- bleeds, sinus trouble.Throat(or mouth and Pharynx): Condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, sore tongue, dry mouth, frequent sore throats, hoarseness.-Neck“Swollen Glands,” goiter, lumps, pain, or stiffness in the neck.-BreastLumps, pain, or discomfort, nipple discharge-RespiratoryCough, sputum (color quantity; presence of blood or hemoptysis), shortness of breath (dyspnea), wheezing, pain with a deep breath (Pleuritic pain).-Cardiovascular“Heart trouble”; high blood pressure; rheumatic fever; heath murmurs; chest pain or discomfort; palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea); need to sit up at night to ease breathing (paroxysmal nocturnal dyspnea) swelling in the hands , ankles, or feet (edema).-GastrointestinalTrouble swallowing, heartburn, appetite, nausea. Bowel movements, stool color and size, change bowel habits, pain constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver, or gallbladder trouble.-Peripheral VascularIntermittent leg pain with exertion (Claudication); leg cramps; varicose veins; past clots in the veins; past clots in the veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness.-UrinaryFrequency or urination,  polyuria, nighttime urination (nocturia), urgency, burning or pain during urination, blood in the urine (hematuria), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence;  in males, reduced caliber or force of the urinary stream, hesitancy, dribbling.-GenitalMale:Hernia, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infection and their treatments. Sexual interest (Libido), function, satisfactionFemale:Menstrual regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, dysmenorrhea, premenstrual tension. Menopausal symptoms, post-menopausal bleeding. Vaginal discharge, itching, sores, lumps, sexually transmitted infection, and treatments. Sexual interest, satisfaction, any problems, including pain during intercourse (dyspareunia)-MusculoskeletalMuscle or joint pain, stiffness, arthritis, gout, backache. If present, describe the location of affected joints or muscles, any swelling, redness, pain , tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness.-PsychiatricNervousness, tension, mood, including depression, memory change, suicidal ideation, suicide plans or attempts.-NeurologicChanges in mood, attention, or speech;  changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis, numbness, loss of sensation, tingling or “pins and needles,” tremors or other involuntary movement seizures.-HematologicAnemia, easy bruising, or bleeding-EndocrineHeat or cold intolerance, excessive sweating ,excessive thirst (polydipsia), hunger (polyphagia), or urine output (polyuria).-Physical ExaminationGeneral Survey:MN is a short, overweight middle-aged female, who is animated and responds quickly  to questions. Her hair was well groomed. Her color is good, and she lies flat.Vital Signs:Ht(without shoes) 157 cm (5’2”). Wt (dressed) 65 kg (143 lbs) . BMI 26, BP 164/98 right arm supine; 160/96 left arm, supine; 152/88 right arm, supine with wide cuff. Heart rate (HR) 88 and regular. Respiratory rate (RR) 18. Temperature (oral) 98.6F.Skin:Palms cold and moist, but color good. Scattered Cherry angiomas over upper trunk. Nails without clubbing , cyanosis.Head, Eyes, Ears, Nose, Throat (HEENT): Head;hair of average texture, Scalp without lesions, normocephalic/ atraumatic (NC?AT).Eyes;Vision 20/30 in each eye.Visual fields full by confrontation. Conjunctive pink; sclera white. Pupils 4 mm constricting to 2 mm, round, regular, equally reactive to light. Extraocular movements intact. Disc margins sharp, without hemorrhage, exudate. No arteriolar narrowing or A-V nicking.Ears:Cerumen partially obscures right tympanic membrane (™); Left canal clear, ™ with good cone of light. Acuity is a good to whispered voice. Weber midline. AC>BC.NoseMucosa pink, septum midline. No sinus tenderness.Mouth:Oral mucosa pink. Dentition is good. Tongue midline. Tonsils absent. Pharynx without exudates.Neck:Neck Supple. Trachea midline. Thyroid isthmus barely palpable, lobes not felt.Lymph Nodes:No cervical, axillary, or epitrochlear nodes.Thorax and Lungs:Thorax Symmetric with good excursion. Lungs resonant on percussion. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.Cardiovascular:Jugular venous pressure 1 cm above the sternal angle, with the head of the examining table raised to 30 degrees. Carotid upstrokes brisk, without bruits. Apical impulse discrete and tapping, barely palpable in the 5th left interspace, 8 cm lateral to the midsternal line. Good S1,,.S2,: no S3 or S3,. A II/VI medium-pitched midsystolic murmur at the 2nd right interspace; does not radiate to the neck. No diastolic murmurs.Breast:pendulous, symmetric.. No masses; nipples without discharge.Abdomen:Protuberant. Well-healed scar, right lower quadrant. Bowelsounds active. No tenderness or masses. Liver span 7cm  in right midclavicular line; edge smooth, palpable 1 cm below right costal margin (RCM). Spleen not felt. No costovertebral angles tenderness (CVAT).Genitalia:FemaleExternal genitalia without lesions. Mild cystocele at introitus on straining. Vaginal mucosa pink. Cervix pink, parous, and without discharge. Uterus anterior, midline, smooth, not enlarged . Adnexa is not palpated due to obesity and poor relaxation. No cervical or Adnexal tenderness. Pap Smear taken. Rectovaginal wall intact.MaleExternal genitalia without discharge or lesions. No scrotal or testicular mases or swelling, no hernia.Rectal:No external hemorrhoids, tight sphincter tone, rectal vault without masses, stool brown negative for occult blood.Extremities:Bilateral upper extremities warm. Bilateral lower extremities; no edema. Calves supple, symmetric, temperature intact bilaterally with negative Homan’s sign.Peripheral vascular:No varicosities in lower extremities. No stasis pigmentation or ulcers Pulses. (2+ = normal)_________________________________________________________Radial           Femoral      Popliteal       Dorsalis Pedis    Posterior Tibial_________________________________________________________Rt 2+ 2+ 2+ 2+ 2+_______________________________________________________Lt 2+ 2+ 2+ 2+ 2+Musculoskeletal:No joint deformities or selling on inspection and palpation. Good range of motion in hands, wrists, elbows, shoulders, spine, hips, knees, ankles.Neurologic: Mental Status:Alert and cooperative. Thought processes are coherent and insight is good. Oriented to person, place, and time. Cranialnerves:II to XII intact.Motor:Good muscle bulk and tone.Strength:5/5 bilaterally in deltoids, biceps, triceps, hand grips, iliopsoas, hamstrings, quadriceps, tibialis anterior, and gastrocnemius.Cerebellar:Rapid Alternating movements (RAMs)  and point-to-point movements intact. Gait stable, fluid.Sensory:Pinprick, light touch, position sense, vibration, and stereognosis intact. Romberg negative.Reflexes:Bilateral triceps, brachioradialis, patellar and Achilles deep tendon reflexes intact. Bilateral plantar reflex intact. Babinski response is negative.CASESTUDY5OBUM.docxCOMPREHENSIVE CASE STUDY – CHIEF COMPLAINT – SHOULDER PAINHistory of Present IllnessA 26-year-old male firefighter presents to his PCP following an ED visit for an episode of dehydration and severe muscle pain experienced during rigorous physical activity. Yesterday, he fought a fire for an extended period under extreme physical conditions. Despite consuming significant amounts of water, he began feeling lightheaded, experienced severe pain in his calves and shoulders, and noticed dark-colored urine. He was evaluated in the ED and discharged with instructions to hydrate. However, he continues to have dark-colored urine, generalized muscle pain, and fatigue. He reports feeling “like I’ve been hit by a truck.”Review of Systems (ROS)Positive:Weakness, exhaustion, palpitations, shortness of breath, nausea, dark-colored urine, muscle pain (shoulders, lower back, calves).Negative:Diarrhea, constipation, anuria, hematuria, muscle weakness, numbness, tingling.Past Medical History:Recurrent musculoskeletal injuries (shoulder, knee), HTN, and anxiety.Social History:Moderate alcohol use (occasional beer), no tobacco or drug use. Unmarried in a casual relationship with no children. Active lifestyleFamily History:Mother with breast cancer (remission), father without chronic conditions. Sibling brother with Hx chronic migrainesAllergies:None.Medications:Ibuprofen 200mg PO q 8 hrs PRN muscle aches, Lisinopril 2.5mg PO daily, Lexapro 10mg PO daily.Physical ExaminationVitals:T 37.3°C (99.1°F), P 96BPM, RR 12 BPM, BP 134/86, BMI 29.7.General:A&O; no acute distress; overweight.Skin:No erythema, pallor, or abnormalities noted.HEENT:Normal findings.Lungs:Vesicular breath sounds throughout, equal bilaterally.Cardiac:Regular rate and rhythm, no murmurs/rubs/gallops.Abdomen:Soft, mild epigastric tenderness, bilateral flank tenderness, no CVA tenderness.Musculoskeletal:Tenderness over bilateral shoulders, reduced ROM due to pain, generalized tenderness of calves and quadriceps, severe paralumbar tenderness with guarding and hypertonicity.Neurological:A&O×3; cranial nerves intact.CLINICAL DISCUSSIONBased on the subjective and objective information presented,select and prioritize threedifferential diagnoses, including each diagnosis’s rationale,pathophysiology, and pertinent positives and negatives.For the working diagnosis, explain why this is the primary diagnosis, what physical findings support the primary diagnosis, and list any additional body systems not addressed in the physical exam and how those physical findings could further support your primary diagnosis.·  List any additional questions you may have inquired about in your history taking that have not already been presented in the HPI and are necessary to establish your diagnosis.· Address any necessary laboratory or diagnostic testing and the clinical significance of these diagnostics for your diagnosis or ultimate treatment plan.· Discuss the next appropriate steps in your management and at leasttwo potential complications of this diagnosis untreated.· Finally, discuss medication management, including pharmacologic and nonpharmacologic choices with appropriate dosing, comprehensive patient education, and follow-up recommendations.Recall the necessary components in your case studies from NUR631. We will continue to build on the format throughout the clinical aspect of adulthood.APA format with at least FIVE peer-reviewed references to support diagnosis, management, and patient education.APA FORMAT, AND REFERENCES, peer review scholarly resource cited in APA format from 2019-2024 only. (Within the last five years)Please do not solely use a website as your scholarly reference. While it is fine to use it as a supplement, a journal article or text should be referenced.Please use North American peer-reviewed journals,DO NOT use any European JournalPlease use reliable medical references such as the Current Medical Diagnosis and Treatment book or UpToDate. Do not use WebMD, Wikipedia, etc., as these are not advanced practice references.APA format (if using outside sources).CriterionExemplary (Full Points)ProficientSatisfactoryNeeds ImprovementUnsatisfactoryDifferential Diagnosis Development and Justification (30 Points)30–26 Points: Identifies three well-prioritized differential diagnoses with clear and accurate rationale. Pathophysiology is detailed and evidence-based. Pertinent positives and negatives are comprehensive and clearly linked to the clinical presentation.25–21 Points: Identifies three differential diagnoses with adequate rationale and pathophysiology. Pertinent positives and negatives are mostly accurate but may lack depth or clarity.20–16 Points: Identifies three differential diagnoses but with limited rationale or incomplete pathophysiology. Pertinent findings are minimally addressed or lack depth.15–11 Points: Fewer than three differential diagnoses, or rationale and pathophysiology are unclear or incorrect. Pertinent findings are not fully addressed.10–0 Points: Little to no effort to develop differential diagnoses, rationale, or supporting findings.Working Diagnosis and Supporting Evidence (20 Points)20–18 Points: Working diagnosis is logically prioritized and strongly supported with clinical evidence. Additional body systems and findings are identified and well-justified.17–15 Points: Working diagnosis is clearly identified and supported by evidence, though explanation of additional systems or findings may lack depth or specificity.14–12 Points: Working diagnosis is identified but lacks a thorough explanation or fails to integrate key clinical evidence. Additional systems are mentioned but minimally explained.11–8 Points: Working diagnosis is unclear or poorly supported by clinical evidence. Additional systems are not addressed or lack rationale.7–0 Points: Working diagnosis is absent or unsupported by clinical reasoning.History, Diagnostic Testing, and Relevance (20 Points)20–18 Points: Comprehensive history questions are identified, relevant to the case, and explained thoroughly. Diagnostic testing choices are appropriate and well-rationalized, with clear connections to the diagnosis and management.17–15 Points: History questions and diagnostics are mostly appropriate and relevant, though some explanations or connections to the case may be incomplete.14–12 Points: History and diagnostics are partially appropriate but lack depth or connection to the diagnosis and management.11–8 Points: History and diagnostics are incomplete or minimally relevant, with little explanation of their significance.7–0 Points: Few or no relevant history questions or diagnostic tests are identified.Management Plan and Complications (20 Points)20–18 Points: Comprehensive management plan includes pharmacologic and non-pharmacologic treatments with appropriate dosing and monitoring. Potential complications of untreated diagnosis are well-described and clinically relevant.17–15 Points: Management plan addresses most key elements but may lack depth or specificity in treatment choices or complication discussion.14–12 Points: Management plan includes some key elements but lacks clarity or thoroughness in treatment options or addressing complications.11–8 Points: Management plan is incomplete or poorly justified. Complications are minimally addressed or not relevant.7–0 Points: Management plan is absent or not relevant to the case.Patient Education and Follow-Up (10 Points)10 Points: Comprehensive patient education addresses lifestyle changes, medication use, and symptom monitoring. Follow-up recommendations are detailed and appropriately prioritized.9–8 Points: Patient education and follow-up are thorough, though some aspects of lifestyle or symptom management may lack detail.7–6 Points: Patient education and follow-up are included but lack depth or specificity in addressing lifestyle or treatment adherence.RubricROS_Template_2023.docx-GeneralUsual weight, recent weight change, weakness, fatigue, or fever-SkinRashes, lumps, sores, itching, dryness, changes in color, changes in hair or nails, changes in size or color moles-Head, Eyes, Ears, Nose, Throat (HEENT):-Head: Headache, head injury, dizziness, lightheadedness.Eyes: Vision, glasses or contact lenses, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts.Ears: Hearing, Tinnitus, Vertigo, earaches, infection, discharge, If hearing is decreased, use or nonuse of hearing aids,Nose and Sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nose- bleeds, sinus trouble.Throat(or mouth and Pharynx): Condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, sore tongue, dry mouth, frequent sore throats, hoarseness.-Neck“Swollen Glands,” goiter, lumps, pain, or stiffness in the neck.-BreastLumps, pain, or discomfort, nipple discharge-RespiratoryCough, sputum (color quantity; presence of blood or hemoptysis), shortness of breath (dyspnea), wheezing, pain with a deep breath (Pleuritic pain).-Cardiovascular“Heart trouble”; high blood pressure; rheumatic fever; heath murmurs; chest pain or discomfort; palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea); need to sit up at night to ease breathing (paroxysmal nocturnal dyspnea) swelling in the hands , ankles, or feet (edema).-GastrointestinalTrouble swallowing, heartburn, appetite, nausea. Bowel movements, stool color and size, change bowel habits, pain constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver, or gallbladder trouble.-Peripheral VascularIntermittent leg pain with exertion (Claudication); leg cramps; varicose veins; past clots in the veins; past clots in the veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness.-UrinaryFrequency or urination,  polyuria, nighttime urination (nocturia), urgency, burning or pain during urination, blood in the urine (hematuria), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence;  in males, reduced caliber or force of the urinary stream, hesitancy, dribbling.-GenitalMale:Hernia, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infection and their treatments. Sexual interest (Libido), function, satisfactionFemale:Menstrual regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, dysmenorrhea, premenstrual tension. Menopausal symptoms, post-menopausal bleeding. Vaginal discharge, itching, sores, lumps, sexually transmitted infection, and treatments. Sexual interest, satisfaction, any problems, including pain during intercourse (dyspareunia)-MusculoskeletalMuscle or joint pain, stiffness, arthritis, gout, backache. If present, describe the location of affected joints or muscles, any swelling, redness, pain , tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness.-PsychiatricNervousness, tension, mood, including depression, memory change, suicidal ideation, suicide plans or attempts.-NeurologicChanges in mood, attention, or speech;  changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis, numbness, loss of sensation, tingling or “pins and needles,” tremors or other involuntary movement seizures.-HematologicAnemia, easy bruising, or bleeding-EndocrineHeat or cold intolerance, excessive sweating ,excessive thirst (polydipsia), hunger (polyphagia), or urine output (polyuria).-Physical ExaminationGeneral Survey:MN is a short, overweight middle-aged female, who is animated and responds quickly  to questions. Her hair was well groomed. Her color is good, and she lies flat.Vital Signs:Ht(without shoes) 157 cm (5’2”). Wt (dressed) 65 kg (143 lbs) . BMI 26, BP 164/98 right arm supine; 160/96 left arm, supine; 152/88 right arm, supine with wide cuff. Heart rate (HR) 88 and regular. Respiratory rate (RR) 18. Temperature (oral) 98.6F.Skin:Palms cold and moist, but color good. Scattered Cherry angiomas over upper trunk. Nails without clubbing , cyanosis.Head, Eyes, Ears, Nose, Throat (HEENT): Head;hair of average texture, Scalp without lesions, normocephalic/ atraumatic (NC?AT).Eyes;Vision 20/30 in each eye.Visual fields full by confrontation. Conjunctive pink; sclera white. Pupils 4 mm constricting to 2 mm, round, regular, equally reactive to light. Extraocular movements intact. Disc margins sharp, without hemorrhage, exudate. No arteriolar narrowing or A-V nicking.Ears:Cerumen partially obscures right tympanic membrane (™); Left canal clear, ™ with good cone of light. Acuity is a good to whispered voice. Weber midline. AC>BC.NoseMucosa pink, septum midline. No sinus tenderness.Mouth:Oral mucosa pink. Dentition is good. Tongue midline. Tonsils absent. Pharynx without exudates.Neck:Neck Supple. Trachea midline. Thyroid isthmus barely palpable, lobes not felt.Lymph Nodes:No cervical, axillary, or epitrochlear nodes.Thorax and Lungs:Thorax Symmetric with good excursion. Lungs resonant on percussion. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.Cardiovascular:Jugular venous pressure 1 cm above the sternal angle, with the head of the examining table raised to 30 degrees. Carotid upstrokes brisk, without bruits. Apical impulse discrete and tapping, barely palpable in the 5th left interspace, 8 cm lateral to the midsternal line. Good S1,,.S2,: no S3 or S3,. A II/VI medium-pitched midsystolic murmur at the 2nd right interspace; does not radiate to the neck. No diastolic murmurs.Breast:pendulous, symmetric.. No masses; nipples without discharge.Abdomen:Protuberant. Well-healed scar, right lower quadrant. Bowelsounds active. No tenderness or masses. Liver span 7cm  in right midclavicular line; edge smooth, palpable 1 cm below right costal margin (RCM). Spleen not felt. No costovertebral angles tenderness (CVAT).Genitalia:FemaleExternal genitalia without lesions. Mild cystocele at introitus on straining. Vaginal mucosa pink. Cervix pink, parous, and without discharge. Uterus anterior, midline, smooth, not enlarged . Adnexa is not palpated due to obesity and poor relaxation. No cervical or Adnexal tenderness. Pap Smear taken. Rectovaginal wall intact.MaleExternal genitalia without discharge or lesions. No scrotal or testicular mases or swelling, no hernia.Rectal:No external hemorrhoids, tight sphincter tone, rectal vault without masses, stool brown negative for occult blood.Extremities:Bilateral upper extremities warm. Bilateral lower extremities; no edema. Calves supple, symmetric, temperature intact bilaterally with negative Homan’s sign.Peripheral vascular:No varicosities in lower extremities. No stasis pigmentation or ulcers Pulses. (2+ = normal)_________________________________________________________Radial           Femoral      Popliteal       Dorsalis Pedis    Posterior Tibial_________________________________________________________Rt 2+ 2+ 2+ 2+ 2+_______________________________________________________Lt 2+ 2+ 2+ 2+ 2+Musculoskeletal:No joint deformities or selling on inspection and palpation. Good range of motion in hands, wrists, elbows, shoulders, spine, hips, knees, ankles.Neurologic: Mental Status:Alert and cooperative. Thought processes are coherent and insight is good. Oriented to person, place, and time. Cranialnerves:II to XII intact.Motor:Good muscle bulk and tone.Strength:5/5 bilaterally in deltoids, biceps, triceps, hand grips, iliopsoas, hamstrings, quadriceps, tibialis anterior, and gastrocnemius.Cerebellar:Rapid Alternating movements (RAMs)  and point-to-point movements intact. Gait stable, fluid.Sensory:Pinprick, light touch, position sense, vibration, and stereognosis intact. Romberg negative.Reflexes:Bilateral triceps, brachioradialis, patellar and Achilles deep tendon reflexes intact. Bilateral plantar reflex intact. Babinski response is negative.12Bids(62)PROVEN STERLINGDr. Ellen RMEmily ClareMathProgrammingDr. Aylin JMDr. Sarah BlakeMISS HILLARY A+Prof Double RSTELLAR GEEK A+Young NyanyaProWritingGurugrA+de plusDr. Adeline Zoefirstclass tutorDr M. MichelleCreative GeekDr. Sophie MilesWIZARD_KIMMUSYOKIONES A+Isabella HarvardShow All Bidsother Questions(10)Micro Bio discussion(bacterial cell walls) 200-250 wordsCreate a handout to give strategies for effective communication, and a separate narrative to evaluate communication strategies most appropriate for your chosen disaster or catastrophic eventPharm wk 4 CASE STUDIESlorem,ipsum,APN business planningEducation AssignmentCase 2Mathematics – Statistics HOMEWORK 8 PSYTransition planCase Study: Jax

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