onstruct a case study summary from the assigned case study CV: denies history heart murmur, heart
onstruct a case study summary from the assigned case study CV: denies history heart murmur, heart problems At the conclusion of the summary answer the following questions: What are the components of an effective oral case presentation and which did you use in your summary? Which of the NONPF core competencies are you demonstrating in summarizing the case?Case DescriptionCC: difficulty swallowingHPI: 32-yr-old female with a 5-day history of runny nose, sore throat, congestion and cough. The symptom that bothers her the most is the cough because it wakes her up at night. She denies smoking. She drinks a class of wine at diner about 4 days a week. She is married and has 2 children age 5 and 8. Her 5 year-old came home about a week ago with a “cold”. She denies a history of asthma and allergies. She adds that since she is here she would like a refill on her SSRI. Her mood is “fine”.PMH Denies chronic diseasesDenies surgeriesGYN: LMP (2 weeks ago) G 2 P 2 live full term vaginal deliveriesDenies STIs ever, HIV test 12/08 negative, last pap 1 year ago negative results, does self breast exam monthlyDiet: vegetarianSleep 8 hours a nightExercise: goes to the Y 4-x week Zumba ClassSocial: college degree, occupation administrative assistant, home owner and lives with husband and two children, bi-lingual English and Spanish, no religious affiliation. No advance directive completed. She has a history of arrest for “Pot” in High School. She denies guilty plea and explains it was her brother’s stash but she could not tell anybody at the time. It has been erased from her record.Last Dental appointment 4 months ago, gets teeth cleaned 2-x year, brushes and floss twice a day. ROS:General: Denies weight loss, fever, fatigue, chills Skin: denies skin rashes, moles recent changes, + blistering sunburn in childhoodH: denies traumaE: no glasses, pain, trauma, dischargeE: no problems with hearing, pain, dischargeN/Oral: see HPIN: denies history problems with Thyroid, no enlarged lymph nodes, no painPulm: + cough, no history asthma, smoke cigarette no/never see HPIGI: denies N/V/D last BM today AM soft brown no bloodGYN/GU: denies vaginal discharge, pain, one sex partner husband monogamous relationshipMS: denies pain, injury, problems with jointsExt: denies edemaNeuro: denies headache, history of seizure Exam: Ht 5′ 2″ Wt: 105 BP 100/60 HR 96 RR 14 Temp: 99.9Gen: WNWD White female alert and anxious, coughing during interviewSkin: pink, warm, dry, no rashesHEENT: Sclera clear, EMO’s intact, PERRLA, TMs grey, canal clear bilaterallyOral: Pharynx erythematous, tonsils + 2 bilateral uvula Uvula midline, good dentition, no order, buccal membranes moist pink no lesions Neck: no thyroid enlargement or nodules, full ROM, nontender no carotid bruitsPul: course breath sounds bilaterally, no wheezing, no increase fremitusCV: RRR S1 S2 no S3 or S4 no murmurGI: Abd flat, nontender, BS + throughout, no bruits, no organomegalyGU/GYN: not examinedMS: not examined Neuro: CN 2 – 12 intact DTRs +2 bilaterally Mood: anxiousLabs: Rapid Strep test negativeAssessment: Viral URI/BronchitisPlan:Diagnostics: NoneRx: Robitussin with Codeine 1 – 2 teaspoons every 4 hours as needed for cough 120 cc No RefillsEducation: warm beverages or soups, tea with lemon, for sore throat, good hand washing, Motrin or Tylenol for fever, push fluids, can use OTC Sudafed as needed for runny noseF/U: Return in 1 week if symptoms persists or get worse Health Science Science Nursing FNP 672 Share QuestionEmailCopy link Comments (0)
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