NKU MSN610 Full Course Latest 2020 March (No Week 4 & 6 Quiz)

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 1 Assignment

Differential Diagnoses Table

Complete and Submit the Differential Diagnoses Table for Module 1 using information from Stern, S., Cifu, A., and Altkorn, D., (2015). Symptom to Diagnosis.3rd edition to complete the table.

Read  pages 179-183, 341-342, and  Chapters 18 (Fatigue) and 32 (Unintentional Weight Loss). Chapters 18 and 32 can be associated with generalized symptoms i.e. Fever.

This assignment is designed to assist you in the development of differential diagnoses based on the signs/symptoms,and physical findings of specific disease entities. You will also begin examining the commonly used laboratory, radiological and other diagnostic studies to identify the diagnosis (rule in) and/or exclude the diagnosis (rule out).

Within the table there are identified diagnoses listed that may be associated with a chief complaint. You are to complete each column for each disease entity.

The Epidemiology Data includes the population you would see this diagnosis occur i.e. pediatrics, adult females/males, elderly, etc. Condense this information as you would in the "Illness Script" described in the Medical Media software.

List the  subjective data:  that is what a patient may tell you. Also, list the physical findings of that disorder. This is the objective data that you would discover on exam. Then list 3 other differential diagnosis that may present with the same chief complaint to begin grouping pattern recognition.

USE BULLET POINTS. This is not a narrative

Finally, list any diagnostic testing you would use to finalize the diagnosis and the references used to complete the table. All citations should be in APA format. References should be listed at the bottom of the table.

 

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 2 Assignment

Differential Diagnoses Table

Within the table there are identified diagnoses listed that may be associated with a chief complaint. This assignment will focus on additional diagnoses within the Skin, HEENT and Neck body systems.

Read Chapters 14 (Dizziness), 20 (Headache), 29 (Rash) and 30 (Sore Throat) within Stern, Cifu&Altkorn to complete your table.  Use Bullet Points !!

Complete the table and submit to your faculty by the due date.

 

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 3 Assignment

Within the table there are identified diagnoses listed that may be associated with a chief complaint for mental health, substance abuse or seen in the pediatric population. You are to utilize other resources to list the signs/symptoms and physical findings of that disorder. Also include in what patient population this disorder may be seen

READ Chapter 11 (Dementia/Delirium) in Stern, Cifu, and Altkorn.

 

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 4 Assignment

Within the table, there are identified diagnoses listed that may be associated with a chief complaint for the cardiovascular and respiratory systems .

Read Chapters 9 (Chest Pain), 15 (Dyspnea), 17 (Edema), 31 (Syncope) and 33 (Wheezing) from Stern, CIFU and Altkorn (2015) to assist in the completion of your table.

Finally, list any diagnostic testing you would use to finalize the diagnosis and the references used to complete the table.

 

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 5 Assignment

This assignment was locked Apr 18 at 11:59pm.

This assignment will focus on additional diagnoses within Abdomen, Male/Female GU, Female Breast/ Pelvic systems. Complete the table and submit to your faculty by the due date.

You are to read Chapters  3( Abdominal Pain), 13 ( Diarrhea), 19, (GI Bleed), 21 (Hematuria), and 26 ( Jaundice)  within Stern, Cifu and Altkorn (2015) to assist in the completion of the table.

Finally, list any diagnostic testing you would use to finalize the diagnosis and the references used to complete the table.

 

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 6 Assignment

This assignment will focus on additional diagnoses within Musculoskeletal, Neuro and Endocrine systems. Complete the table and submit to your faculty by the due date.

You are to read Chapters  7 (Back Pain), 12 (Diabetes), and 27( Joint Pain) within Stern, Cifu and Altkorn (2015) to assist in the completion of the table.

Finally, list any diagnostic testing you would use to finalize the diagnosis and the references used to complete the table.

 

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 7 Assignment

Northern Kentucky University

MSN 610: Diagnostic Reasoning and Advanced Physical Assessment

Comprehensive History & Physical Exam

DEMOGRAPHICS

Providers Name: ___________________________________ Patient’s Initials: (Data Source)____________________

Date of Exam: _______________________________________________________ Patient’s DOB: _______________

Chief Complaint:                                                                                         Gender/Sexual Orientation: ____________________

 

History of Present Illness:

Past Medical History:

                Active Problems:

                Resolved Problems:

Previous Hospitalizations:

Surgical History:

Allergies:

Current Medications:

Social History:

                Living Arrangements:

                Occupation:

                Environmental Safety:

                Smoking:

                Alcohol:

                Drugs:

                Other Non-Prescribed Drugs:

Diet:

Family History:

Relationship Living or Deceased Age Illnesses Mother       Father       Children       Grandparents

 

Preventative Health/ Anticipatory Guidance: (Age Appropriate)

Safety Issues:

Screenings:

Immunizations:

 

Review of Systems:

 

General:

 

Skin, Hair, Nails:

 

HEENT:

Neck:

Cardiovascular:

Pulmonary:

Abd/GI:

Genitourinary/ Gynecology/ Breast

Musculoskeletal:

Neuro:

Endo/Lymphatic:

Hematology:

Psych:

Physical Exam  

Patient’s Initials: ________                                                                                                     Date of Exam: _________

 

Vital Signs:                          Temp:                        Pulse:                        BP:                           Resp:      

General Appearance:

Skin:

Head/Face:

Ears:

Eyes:

Nose:

Mouth/Throat:

Neck:

Heart:

Lungs:

Abdomen:

Musculoskeletal:

                Sensory:

                Motor:

Peripheral Vascular:

 

Neuro:

                Cranial Nerves:

                 Reflexes:

Cognitive Function:                                                                       

Problem Presentation/Assessment Statement: (Summary of presenting problems)

Assessment:  Problem List (As many or as few as needed)

1)

2)

3)

Plan:

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 2 Quiz

Question 1Which of the following is NOT considered a lesion classification?

A. Dermatitis

B. Papulosquamous

C. Pruritis

D. Vesiculobullous

is a classification of skin disorders that consist of bubble-like vesicles or pustules.

Question 2Inspection of the eye using an ophthalmoscope should include documentation which of the following?

A. Red Reflux

B. Optic Disc

C. Physiological Cup

D. Retinal Vessels

E. All of the Above

Question 3Which of the following is  FALSE?

A. Position of the ear canal for children under age 3 consists of pulling the ear downward, outward and backward.

B. Presbycusis is a common cause of hearing loss in geriatric patients.

C. Crying can make the ear canal and tympanic membrane red.

D. Maternal Diabetes is not associated with increased congenital hearing loss of the newborn.

Question 4Assessment of the nose consists of all the following EXCEPT:

A. Inspect the nose for symmetry and lesions,

B. Inspect the nasal canal for discharge, drainage and  patency.

C. Palpation of the nose and sinuses

D. Percussion of the sinuses.

E. These are all TRUE.

Question 5Assessment of the mouth and throat consists of all the following EXCEPT:

A. Inspect the tongue, gums, teeth and mouth for symmetry, color, edema, lesions and dentition.

B. Evaluate the uvula to move laterally with the patient saying "ah"

C. Evaluate the tonsils

D. Palpate the pre-auricular, post-auricular occipital , tonsilar and submandibular lymph nodes

Question 6Within the diagnostic process, the first step is to identify the problem.  Which of the following biases does NOT interfere with arriving at the correct diagnostic conclusion?

A. Non-Availability

B. Confirmation

C. Representativeness

D. Premature Closure

Question 7Once the problem has been identified and explored, the ranking of the possible differential diagnoses should include which of the following:

A. All the alternative diagnoses should be listed first

B. The most likely diagnosis should be listed last

C. The Must Not Miss diagnoses should be included

D. The "zebra" diagnoses should be included

Question 8Health promotion includes the age appropriate screening recommendations for disease prevention. The screening recommendations may change with the evolution of new evidence. Which of the following would NOT be a reliable reference ?

A. The National Cancer Society

B. The American College of Cardiology

C. The National League of Osteoporosis

D. Us Preventive Services Task Force

Question 9Which of the following hearing acuity test assesses for the comparison of  bone conduction to air conduction bone to each ear separately?

A. Rinne Test

B. Weber Test

C. Whisper Test

Question 10Which of the following statements is FALSE regarding a Hyphema?

A. It can results from trauma or surgery

B. It causes the sclera to appear reddened

C. It is due to blood found in the anterior chamber of the eyes

D. It is the inversion of the eyelid.

 

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 1 Discussion

Case Study 1

Complete both of the Discussion Topics and Submit by the Due Date.

1)  Obtaining a comprehensive health history can be difficult in a variety of situations. In this discussion, choose one type of patient scenarios and describe how you would approach interview and obtain the history. Each student must reply to at least one other student in discussion of the scenario with a different patient scenario.

A) The Angry Patient who has been waiting a long time for an appointment and is disgusted with health care in general.

B) The Internet Patient who obtains all his health information from the Internet and has self -diagnosed his problem.

C) The Unfocused Patient with a 3 inch health record she has brought with her to get a second opinion.

D) The Terminal Patient who has end-stage uterine metastatic cancer who has refused treatment.

Instructions:

      A.  Make your initial post by 11:59pm EST Wednesday of Week 1.

       B. Respond to one other classmate posts by 23:59 EST Saturday of Week 1.

2.  There are both a comprehensive history and physical exam and a focused history and physical exam. Discuss the circumstances and components for each type of history/exam. This discussion DOES NOT require another student response.

Each post should include at least one peer-reviewed reference in

 

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 2 Discussion

Case Study 2

MSN 610    Case Study 2A

C.C. M.A. is a 6 year old female who presents for a sick episodic visit who is accompanied with her mother for sore throat, fever and rash.

HPI:  Her mother states M.A..has been sick for about 4 days which started with a headache. Then she developed a sore throat and runny nose. M.A..now appears feverish and doesn’t feel like eating much.

She normally attends pre-school, but mom has kept her home yesterday and today since she felt feverish. Now, this morning, she has this rash. The rash is “a little itchy”. Mom denies changing laundry detergents, foods, soaps and there has been no known exposure to anyone else with a rash or illness.

M.A. has never had a rash previously.

PMH: Growth percentiles within normal limits on previous visits

Immunizations Record:

DPT given at:       2 mos      4mos     6 mos     18 mos        5 yr

OPV given at:     2 mos      4 mos                    18 mos        5 yr

MMR: given at:                                 13 mos                         5 yr

Hib given at:       2 mos     4 mos      6 mos    18 mos

FH:

Relationship Mortality   Age        Health Problems    Relationship   Mortality       Age      Health Problems

Mother           Alive           27              None                       Father              Alive                 27                      None

MGM              Alive             51              HTN/DM                MGF                  Alive                 48                      HLN

PGM               Alive              45              None       PGF                   Alive                  52                    Prostate CA

SH: Lives with mother but spends every other weekend with father who lives in a suburban area 15 miles away. Mother is an elementary school teacher and Father is an social worker. Parents have been divorced for 2 years. M.A. is doing well in the first grade without social or behavioral problems.

Meds: Children’s Tylenol 1 dose last pm                                Allergies: None

ROS:

General: Mom denies weight loss, fatigue until the last 3 days, generally eats well

Skin: Mom denies birthmarks, scars, no previous rashes

HEENT: Denies dizziness, head trauma, vision trouble, does not wear glasses, has about 3 colds/year, denies swallowing problems, nasal congestion, Admits to sore throat, difficulty swallowing,  but drinking fluids as normal

Neck: Denies lumps, pain, stiffness

Resp: Denies dyspnea or pain, admits to rare non-productive cough for 48 hours

Cardiac: Denies chest pain, irregular heart rate, or edema

Gastrointestinal: Denies nausea, vomiting, diarrhea or abdominal pain

PE:

Vital Signs:          Temp: 100.6     Rest: 26     Pulse: 98     Ht: 50”  Wt: 45 lbs

General: Well developed, well-nourished 6 yo female in no acute distress (NAD)

Skin: confluent, maculopapular rash, no pustules, no desquamation covering trunk, with 6 non-linear vesicles on lower trunk about 10 cm apart.

HEENT: Normocephalic, without masses, lesions, alopecia, conjunctiva pink, PERRL, EOM intact, nares patent without redness, throat with erythema and vesicles scattered in pharynx, tonsils +1 enlargement without exudate, no petechiae on palate or uvula, uvula and tongue is midline , dentition good with missing upper front teeth, TM slightly dull but mobile

Neck: Supple without thyromegaly, + mildly tender anterior cervical lymph palpable

Lungs: clear to auscultation and percussion, tactile fremitus bilaterally equal and normal

1)What are your pertinent positives and associated differential diagnoses?

Answers: Headache, Fever, Sore Throat, Anorexia, itchy, confluent, maculopapular rash with vesicles

Differential Diagnoses for Rash, Sore Throat and Fever:

2)            What diagnostic tests would you order and why?

3)            Write your assessment summary statement:

4)            Health promotion: Given her age what recommendations should you give at this time?

5)            What would you prescribe to treat this condition?

6)            What would your follow up consist of?

 

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 3 Discussion

MODULE 3 CASE STUDY

BJ is a 10 yr old female of Hispanic origin who presents to your exam room with an adult Hispanic male that identifies himself as her uncle. He states that BJ has hurt her Right arm after falling down the steps the day before. He states she did NOT loss consciousness or injury her head. The providers asks BJ, “How did you fall down the steps?” BJ looks down and softly states, “I just tripped and feel:. Both speak with broken English.

PMI: No hospitalization or Surgeries. Immunization History is unknown.

Medications: None                                                         Allergies: None

FH: Parents Living Mother age 24  Father age 30, No Siblings

SH: Both parents work cleaning in the hotel industry. BJ is “home schooled” by her aunt.

ROS:

General: NEG weight loss or gain NEG  fatigue, NEG fever

HEENT: NEG for headache,  congestion, nasal drainage,  vision problems,  throat pain

Cardiac: NEG for chest pain, palpitations, swelling, loss of consciousness

Resp:  NEG Dyspnea, Neg for cough, wheezing, NEG PND

GI: NEG Nausea, Neg for Vomiting, Diarrhea, dysphagia, pain, anorexia

MS: + R Shoulder Joint pain, +Joint Swelling, + for falls

HEME:  +for bruising  NEG for bleeding, Neg night sweats

ENDO: Neg for thirst, heat or cold intolerance

NEURO: NEG dizziness, Neg for confusion, numbness, aphasia

PSYCH: NEG for memory loss, Neg for nervousness, suicidal ideation

PE:

General: thin, small for stated age, unkempt but clean in appearance, sitting on exam cradling her R arm in her lap. She winces in pain with any body movement.

HEENT: Normocephalic, long tangled black hair with thin patches of hair loss in occipital area. R Pinnae with purple bruising. TM clear. NEG Weber and Rinne Test. Brown Eyes symmetrical, PERRL, Normal Light Reflex, Normal EOM and Convergence. Nose centered, nares clear with pale, bloody turbinate’s. Throat with clear pharynx, normal tonsils, uvula midline, poor dentition with missing teeth,

NECK: No JVD, Trachea Midline, No Adenopathy, FROM, + Pain with Lateral movement

CHEST: symmetrical, COR: Reg S1S2, No murmurs, rubs, gallops

RESP: CTA with equal bilateral expansion. Significant ecchymosis R sternomastoid muscle into R subclavicular and post scapular areas

ABD: Ecchymosis in RUQ with tenderness to light palpation. Possible liver enlargement. Bowel Sounds x 4 quadrants

GU: ecchymosis of perineum with vaginal spotting noted on underpants

EXT: No clubbing, cyanosis, pale, sluggish capillary refill in R phalanges nail beds. FROM in LUE & bilateral LE, Severe pain with attempts to abduct RUE. +3 pedal, femoral, brachial, radial pulses

Psych: Alert, Oriented to Place and Time. Quiet, withdrawn mood, Flat affect, avoids eye contact

Vital Signs:     HT:   53 inches         WT: 60    TEMP: 99   BP: 100/50    HR: 90    RESP 30     O2SAT: 95%

Discussion Questions:What diagnostic tests would you order and why? What referrals would you request? How else can you document/validate your physical findings? What would you do if uncle refused the testing or treatment?   Although this is a case of child, this could easily be an elderly 75 year old brought in by a family member. What would you do differently if this an adult?

 

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 4 Discussion

Case Study 4

Northern Kentucky University

MSN 610: Diagnostic Reasoning and Advanced Physical Assessment

Module 4 Case Study

K.H. is a 16 year old male who presents to your exam room with recurrent episodes of dyspnea. His mother is with him and reports he has been in his usual good health until this past fall football season ( 4 months ago), when she noticed him wheezing after activities. Usually the wheezing would resolve spontaneously after a couple of minutes of rest. When you ask K.H. how often he feels SOB, he states it has gotten worse and now even walking up a flight of steps causes wheezing and coughing. He also admits to increased fatigue with decreased exercise tolerance.

PMH: Croup as an infant. Recurrent URIs as a child. Immunizations are Up To Date.

Surgical History includes PE tubes at age 3 for chronic OTM(Otitis Media)

Medications: None                                                                         Allergies: Amoxicillin (hives)

SH: Breast fed x 6 month. Normal Developmental Milestones. Currently in grade 10 at local high school. Active in sports (football, baseball) Grades: As and Bs. + Smoking 3-4 cigs per day x 1 year. Neg for ETOH (alcohol)

Denies illegal drugs. Lives at home with both parents and sister

FH: Mother living @ age 36 with Hypertension and Hypothyroidism – Asthma, - Pneumonia - Smoking

       Father living @ age 40 with GERDS -Asthma -Pneumonia + Smoking 1 ppd x 10 years

       Siblings: 1 Sister age 13 with recurrent URIs

ROS:

General: Denies weight changes, fever, chills

Head: Denies trauma, headaches, hair loss

EENT: Denies vision changes, earaches,  hearing loss,  congestion, nosebleeds, sore throat or hoarseness

Neck: Denies dysphagia, swollen glands or stiffness

PUL: Admits to SOB, Wheezing, and Cough . Denies sputum or sneezing

CAR: Admits to chest pain, worse with deep breaths, Denies palpitations, swelling. Sleeping sitting up x 1 week.

GI: Not eating well x 1 week. Denies N/V/D/ Constipation

GU: Denies urinary frequency, pain or incontinence, or discharge

PVD: Denies leg pains, numbness or tingling

HEME: Denies bruising or bleeding

PSYCH: Denies forgetfulness, depression. He admits to being worried about his breathing and being able to play sports.

WT:  150 lb s      HT: 5’5BMI:          Temp:           BP: 135/90       HR: 100       Resp.24          O2 Sats: 88%

PE: K.H. is a 16 year old male who appears stated age, well groomed with tachypnea and appears anxious.

HEENT: Normocephalic, Atraumatic. Hair is evenly distributed.

Eyes: Symmetrical, sclera and conjunctiva normal color PERRL

Ears: Auricles equally symmetrical, non-tender. TMs clear with normal structures. Weber: Equal lateralization

Rinne: AC> BC bilaterally. Nares patent. Turbinates  pale. Pharynx: Clear. Good dentitian. Uvula midline. Tonsils pink without enlargement

Neck: Trachea midline  Neg for Thyromegaly or nodules. Neg: Carotid Bruits Neg: JVD + Lymphadenopathy

Lungs: Inspiratory/expiratory wheezes 2/3 lobes with decreased breath sounds @ bases bilaterally. Cough induced with deep inspiration. Hyper-resonance with percussion. Fremitus decreased at the bases. Mild anterior retractions noted.

Cardiac: Reg S1S2 with early systolic murmur @3-4 ICS (intercostal space) Left MCL (Mid clavicular line).PMI @ 4th MCL w/o thrills

Abd: soft, non-tender, BS x  quads. No masses, No scars Neg hepatomegaly  Neg Splenomegaly

Ext: Diaphoretic, Pale, Neg Clubbing, Pale, sluggish capillary refills .FROM (Full Range of Motion) all extremities

Psych: Anxious, frequently looking at mom to help with answers and during the exam. Alert, Cooperative, Oriented x 4. Subdued Mood.

1)            What other  information would you like to obtain?

2)            What are the initial H & P “red flags” are cause for concern? (Pertinent Positives)

3)            What diagnostic tests/interventions would you perform?

4)            What would you include in your differential?

 

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 5 Discussion

Case Study 5

CC: J.D. is a 32 year old male presents to your office for a complete physical exam as a new patient. He c/o intermittent episodes of diarrhea, abdominal discomfort, bloating and occasional constipation.

HPI: J.D. states he often eats a meal and within 10 minutes, he feels bloated and “gassy”. He frequently has periods of nausea, urgent watery diarrhea. This is embarrassing for him as he is not always near a bathroom. This has become progressively worse over the last years and occurs almost daily. He first realized he was having bowel problems when he was in high school when he played on the football team. Diarrhea always seemed to get worse on game day. He denies vomiting or laxative use.

PMH: No hospitalizations or surgeries. His childhood immunizations were all completed and he had a tetanus booster 5 years ago. Only health problem has been his abdominal bloating and “bowel problems”. He was treated for strep throat and a sinus infection 5 years ago with Amoxicillin.

FH:         Relationship                       Mortality             Age                        Health Problems

                Mother                                                Alive                      54                           None

                Father                                   Alive                      56                           Arthritis

                MGM                                    Alive                      70                           HTN, Rheumatoid Arthritis, HLN

                PGM                                      Alive                      66                           Breast CA, Pacemaker

                PGF                                        Alive                      67                           None

                MGF                                      Deceased            65                           CVA

SH:         He is a graduate student at the university studying Psychology. He lives in an apartment with his girlfriend.

He drank heavily in high school, but may have 1 glass of wine weekly. Denies smoking cigs/marijuana or IV drug use.  He exercises regularly but his diet is “awful” and depends on how hectic his schedule is. He is currently working full time as a bank teller.

Meds: None                                                                                                       Allergies: None

ROS:

General: Fair appetite with no weight loss, Denies fatigue, fever, chills, blood transfusion

Skin: Denies rashes, lesions, scars

HEENT: Denies dizziness, headaches, head trauma, vision or hearing difficulties, Sees dentist annually, Denies allergies, nasal congestion, sinus problems, dysphagia

Neck: Denies lumps, pain, stiffness

Cardiac:  Denies chest pain, dyspnea on exertion, palpitations

Resp:  Denies dyspnea, cough, wheezing

Gastrointestinal:  See HPI

Genitourinary: Denies dysuria, frequency, hematuria, penile discharge, heterosexual but libido is low as he frequently just does not feel well.

Musculoskeletal: Denies joint pain, swelling, arthritis, myalgia

Endocrine: Denies skin or hair changes, temperature intolerances, excessive thirst or urination

Neurological: Denies weakness, seizures,

Psychological: Denies depression, but admits he sometimes gets “anxious” with graduate school and work.

Nutritional: Admits he eats 1 meal/day usually in the evening when “life has quieted down”. This meal consists of some meat/potato. Salads causes bloating. Snacks can cause cramping and diarrhea in the afternoon-so I just don’t eat. Milk products do not seem to bother him.

Physical Exam:

Vital Signs:   Temperature 98       Pulse: 76 b/min      Resp:  16/mi     BP: 120/80     HT: 5’11  WT: 174   BMI: _____

General Appearance:  Well developed, well nourished, appropriately groomed and appears his stated age

Skin: Smooth, soft, w/o lesions, rashes, scars. Tattoo of an eagle on his chest.

HEENT: Normocephalic with evenly distributed hair. No redness or lesions of his eyes, extraocular movements (EOM) intact.

Ophthalmic Exam: Red reflex intact bilaterally. Optic Disc is round creamy yellow with clear margins. Retinal vessels are bright red without exudate, edema, and wool spots. Macula is positive for foveal light reflex.

Otoscopic Exam: No ear discharge, TM grey and intact, crisp cone of light

Nose: patent nasal airways, no exudates, turbinates pink without polyps

Mouth: Good dentition, no lesions, buccal tissue pick, tongue/uvula midline, pharynx unremarkable

Neck: No lymphadenopathy, thyromegaly, Has Full ROM, No JVD

Heart: Regular S1S2 w/o gallops, rubs, or murmurs, PMI @ 5ICS MCL

Lungs: Clear to auscultation bilaterally with equal excursion and normal tactile fremitus

Abdomen: soft, no masses, no HJR, no organomegaly, slight diffuse tenderness with light palpation in lower abdomen

Bowel sounds: hyperactive in 4 quads. Rectum: empty, no masses with normal tone. No hemorrhoids or fissures

Hemoccult: Negative

Genitourinary: No palpable inguinal nodes, circumcised penis without lesions, edema, erythema or discharge. Testes descended without masses or tenderness, negative for inguinal hernia

Peripheral Vascular: No edema with +2 palpable radial, popliteal, pedal pulses bilaterally

Musculoskeletal: FROM of all extremities, no joint swelling, pain in upper or lower extremities

Neurological: CN 2- 12 grossly intact

Psychological: Alert, pleasant but subdued. Cooperative and follows commands. Communicative with focused answers.

What are your pertinent positives and your differential diagnoses?

What diagnostic tests would you proceed to order?

Since this is a new patient, what anticipatory guidance would you recommend?

               

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 6 Discussion

Case Study 6

CC: 85 year old female presents to your exam room with “memory loss”

HPI: J.B. is brought in with her son who states his mom is forgetting to pay her bills over the last 4 months and “gets lost” in her own home. J.B. admits she sometimes gets “forgetful”. Her previous PCP retired 6 months ago and they have no medical records with them.

PMH: Total Abdominal Hysterectomy 20 years ago. G3P2 1 Miscarriage. No other surgeries or hospitalizations. Treated for HTN, A-fib

Medications: HCTZ 25 mg daily                                                   Allergies: None

                         Digoxin 0.25 mg daily

                         Coumadin 1 mg daily

                         Multivitamin daily

FH:         Relationship       Mortality             Age        Health Problems

               Mother                 Deceased            54           Diabetes Mellitus II

                Father                   Deceased            75           CAD

                Daughter             Deceased            20           MVA

                Son                        Alive                      45           None

ROS:

General: Denies weight loss, fatigue until the last 3 days, generally eats well

Skin: Denies  birthmarks, scars, no previous rashes

HEENT: Denies dizziness, head trauma, vision trouble, does wear glasses, Had cataract surgery in L eye , denies swallowing problems, nasal congestion, 

Neck: Denies lumps, pain, stiffness

Resp: Denies dyspnea or pain, cough, wheezing

Cardiac: Denies chest pain, or edema of extremities, Has had an irregular heart rhythm “for years”

Gastrointestinal: Denies nausea, vomiting, diarrhea or abdominal pain

Genitourinary:  Denies hematuria, dysuria, or odor

Musculoskeletal: Deniesback pains, Admits to knee pain with difficulty walking

Neurological:  Denies seizures, limb weakness, headaches, loss of consciousness

Psychological: Denies depression/anxiety. No suicidal/homicidal ideations.

She likes to color and work on puzzles but sometimes “I loose pieces” that makes me angry.

PE:   Vital Signs:   Temp 98.6         HR: 84                   RESP: 18               BP:  149/90

Constitutional: Thin, frail-looking, well-kempt 85 yo female in NAD (no acute distress)

HEENT: Normocephalic, atraumatic, with thinning grey hair. Eyes with small xanthoma R outer canthus, conjunctiva pale, white sclera, cloudy R cornea, L cornea normal size and color PERRL, EOM intact. Snellen 20/40 using both eyes with glasses

Ophthalmoscopic Exam: Optic Red reflex intact bilaterally. Optic Disc is round creamy yellow with blurry margins. Retinal vessels are bright red without exudate, edema, and wool spots. Macula is positive for foveal light reflex.

Otoscopic Exam: No ear discharge, TM grey and intact, with mild amount of cerumen, crisp cone of light, Whisper test 2/3 bilaterally

Nose: patent nasal airways, no exudates, turbinates pink without polyps

Mouth: Wearing Dentures, no lesions, palate rises symmetrically, tongue/uvula midline, pharynx unremarkable

Neck: Supple without lymphadenopathy, thyromegaly, or carotid bruits, Has Full ROM, No JVD

Heart: Irregular S1S2 w/o gallops, or rubs, Grade II/VI murmur heard at 4th ICS LBS, PMI @ 5ICS MCL

Lungs: Clear to auscultation bilaterally with equal excursion and normal tactile fremitus

Abdomen: soft,thin, with little fat, no masses, no HJR, no hepatosplenomegaly, Hypoactive bowl sounds in 4 quads. Rectum: with brown stool, no masses with normal tone. Small external hemorrhoids or fissures. Stool guaiac: negative

Genitourinary: No palpable inguinal nodes, wearing incontinent pad with faint smell of urine. Perineum intact without discharge, edema or skin lesions. Pelvic Exam deferred

Peripheral Vascular: No edema or cyanosis, or clubbing with +2 palpable radial, popliteal, pedal pulses bilaterally

Musculoskeletal: FROM of all extremities, no joint swelling, pain in upper extremities. Bilateral knees with creaking with extension and mild tenderness with extension. Strength and sensation in upper/lower extremities are symmetrical

Neurological: CN 2- 12 grossly intact. Ambulates slowly without assistance

Psychological: Alert, pleasant but subdued. Cooperative and follows commands. Communicative with focused answers. Distant and Recent memory sketchy.

Previous labs found in local hospital lab records from 2 months prior:

WBC                      4.6                                                                          Sodium                 128 (L)

RBC                        3.45 (L)                                                                 Potassium           5.3

Hgb                        10.13(L)                                                                Chloride               104

HCT                        33.2 (L)                                                                 Albumin               3.8 (L)   

MCV                      78.3 (L)                                                                 Total protein      6.3 (L)

MCH                      28.2                                                                        Alk Phos               100

MCHC                   32.4                                                                        ALT                         22

RDW                      16.2 (H)                                                                                AST                        28

Platelets              221                                                                        LDH                        134

Segs                       66(H)                                                                     T. Chol                  252 (H)

Lymphocytes     21 (L)                                                                     Calcium                                8.4 (L)

Monocytes         8                                                                              FBS                         130 (H)

Based on this information, what is your problem list?

What is the difference between delirium and dementia?

What else is missing and you would need to know?

What additional diagnostic testing would you order?

What health promotion/maintenance measures would you consider?