Submit a complete History
Submit a complete History on Carolyn Cross via I-Human (History ONLY). Use the attached template and follow the grading rubric for all the components necessary. There MUST be at least 3 items reviewed for each body system in the ROS. Submit the written History Document via CANVAS. The complete history is worth a MAX of 3 points. Use the template to review what to include. Use the Grading Rubrics and for points value. The Case Study in Module 6 is a good example of how to write up a complete history.
Northern Kentucky University
MSN 610: Diagnostic Reasoning and Advanced Physical Assessment
Case Study 6
SF is a 52 year old female who presents to your exam room with complaints of numbness & tingling in R hand and leg. She states she noticed some dizziness yesterday when she got up out of bed. Then later yesterday afternoon she started to have trouble with her vision in her R eye. She states it seemed to be harder to see everything. Today she continues with vision problems and now with numbness & tingling. She states she does not remember if she took her medications this morning.
PMH: Hypertension, Endometriosis, DM II.
Surgical History: Total Hysterectomy at age 50 due to Endometriosis
Medications: Lisinopril 20 mg BID and Metformin 500 mg BID
FH: Father living @ age 75 with MI and CABG
Mother living @ age 73 with A-fib, Hypertension and DM II
No Siblings
SH: Single. Lives in rural farmhouse. Works teaching 6th grade. + Smoking ½ ppd x 20 years. Denies ETOH or other drugs
ROS:
General: No weight changes, fatigue, fever or chills
HEENT: + headache x 3 days, No headache, hair loss, + Dizziness + Vision loss, No hearing loss, No tinnitus, congestion, nosebleeds, sore throat, or dysphagia
Neck: No swollen glands, or stiffness
PUL: No dyspnea, cough, wheezing, or sputum
CAR: No chest pain, PND, Swelling or sleep difficulties until last pm. + Palpitations
GI: No appetite changes N/V/D. + Constipation
GU: No menses x 2 yrs. No bloody urine or stool, painful urination, + incontinence
MS: + trouble walking, “dragging R foot” No pain, stiffness, edema in extremities, + trouble holding coffee cup this AM
PE: HT: 56” WT: 150 lbs BP 170/92 HR:110 Resp: 20 O2 Sat: 96% Temp: 98.6
General: Alert, confused 52 yo female, appearing older than stated age with disheveled clothes.
HEENT: Normocephalic, Atraumatic. R eye with slowed pupil response. L eye pupil reactive. R mouth droop.
EOM normal. Limited vision in R peripheral fields. Ear canals clear, TM gray with normal structures. Nares patent w/o flaring. Pharynx clear without erythema or edema. Missing molars bilaterally.
Neck: Trachea midline. No Thyromegaly. No Lymphadenopathy. No JVD
Resp: Lungs clear with equal bilateral expansion. Fremitus equal.
CV: Irregular, rapid S1S2 No murmurs, rubs or gallops. PMI @ 4th ICS, MCL.
ABD: soft, non-tender BS x 4 quads, No guarding, tenderness or organomegaly
Ext: Warm and dry. +1 pitting edema bilateral LE to knees. +2 radial and pedal pulses
MS: R hand grip weaker than L hand, + pronator drift, abnormal gait with favoring R leg. Decreased muscle strength in RLE with passive extension. Decreased sensation RUE & RLE.
Accuchek: 215
Discuss the abnormal history, physical and lab findings. What is your 1st differential diagnosis? What are the cardinal risk factors for this diagnosis? What other conditions are in your differential diagnoses? What other diagnostic tests and interventions would you order from your office?
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