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Week 3 DQ 2 NR 601

  1. (Subjective)

CC – Mild “heartburn” after eating a large meal for at least 2 years.

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Background: Mr. M.J. is a 64-year-old patient of Hispanic descent who presents to the clinic today with concerns about epigastric and substernal pain that has gotten progressively worse over the past 3 months. He has tried over the counter products occasionally with adequate response. Three months ago, he was awakened with severe burning discomfort that extended from his mid-chest to his jaw that lasted 30 minutes before he was able to fall back to sleep. He is now experiencing these attacks about 3 times per week. He has tried avoiding large meals and is now sleeping on two pillows at night to relieve his pain which has improved his pain. The pain now occurs regularly after meals and randomly during the day. He takes antacids with each meal, but the pain still persists. Overall, he considers himself to be very healthy.

HPI:

Current Medications:

PMH:

Social Hx:

Family Hx

Focused ROS and Physical Exam:

ROS:

Objective:

Physical examination:

Primary Diagnosis:

Differential Diagnosis:

Plan:

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Discussion Part One (graded)

Mrs. R. is a 66-year-old Caucasian female who presents to the clinic with pain in her left hip that worsens with walking, bending, standing, and squatting. When asked to describe where the pain occurs, she places her fingers around the anterolateral hip region. She denies any back pain, or pain in the posterior hip or along the lateral thigh. Denies any previous injury, stumbling, tripping or falling. She states that the pain has been getting gradually worse and is almost constant if she walks or stands for a long period of time. She denies back pain, numbness, tingling, or weakness in the extremities. She reports taking Ibuprofen 800 mg approximately 3 times/week whenever she has significant hip pain. She is concerned that she doesn’t know what is causing the pain and that she is having to take increased doses of ibuprofen to manage the pain. She reports a current pain level of 8/10 on the pain scale.

Background Information

She walks approximately 1 mile a day. She recently retired as an office manager 4 years ago.

PMH

Unremarkable

Immunizations

All vaccines are current

Screenings

Never had a colonoscopy

Last mammogram was 5 years ago

Social History

Has an occasional glass of wine with dinner

Does not smoke

Surgical history

Cholecystectomy 20 years ago

Hysterectomy 10 years ago

Current Medications

Ibuprofen 200-800 mg prn for hip pain

Discussion Questions Part One

  • What risk factors does this patient have that might contribute to her hip pain?
  • What ROS would you conduct on this patient?
  • What is your primary diagnosis? What evidence-based resource and patient data supports this diagnosis?
  • What two differential diagnoses are appropriate in this patient’s case? What evidence-based resource and patient data supports these two differential diagnoses?
  • What screening would you choose to best evaluate this patient’s chief complaint?

NR601 Week 4.2

Discussion Part Two (graded)

Physical Exam:

Vital signs: blood pressure 128/84, heart rate 80 respirations 20, temperature 98.5

height 5’3”, weight 130 pounds

General: no acute distress

HEENT: Head normocephalic without evidence of masses or trauma. PERRLA, EOMs intact. Noninjected. Fundoscopic exam unremarkable. Ear canal without redness or irritation, TMs clear, pearly, bony landmarks visible. No discharge, no pain noted. Neck negative for masses. No thyromegaly. No JVD distention

Skin: intact

CV: S1 and S2 RRR, no murmurs, no rubs

Lungs: Clear to auscultation

Abdomen: Soft, nontender, nondistended, bowel sounds present all 4 quadrants, no organomegaly, and no bruits

Musculoskeletal: No pain to palpation; Antalgic gait noted when patient rises from seated position to standing and begins to walk. Active and passive ROM decreased with stiffness

Neuro: Sensation intact to bilateral upper and lower extremities; Bilateral UE/LE strength 5/5.

Discussion Questions Part Two

  • For the primary diagnosis explain how you would proceed with your work-up and include the following: lab work and imaging studies
  • How would you manage this patient pharmacologically? Is it appropriate that she is taking Ibuprofen prn?
  • What non-pharmacological strategies would be appropriate?
  • Describe patient education strategies.
  • Describe follow-up and any referrals that may be necessary.

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