Additional Data I would like to ask the patient additional questions to obtain more subjunctive data for the diagnosis to be appropriate. I want to know if she had similar symptoms before and how long they lasted. As the woman has an allergy, I wonder if some of the mentioned...
Subjective Data The patient is most likely to say that she cannot concentrate on her household duties due to the cold and the lack of energy. This factor might influence her feeling of insecurity towards family life. She might also be willing to know whether her state would last long...
What Questions Would you Ask to Gather Diagnostic Information? In the case of Robert Ross, it would be proper to ask the patient particular questions in order to identify his diagnosis and prescribe medicine. This person has such symptoms as acute chest pain, palpitations, fever, and malaise. These signs tell...
Introduction Sixteen-year-old Jessica reports a 2-month history of fatigue, pallor, and inability to “keep up” with her team mates on the school swim team. Her last menstrual period started yesterday, and her pregnancy test is negative. The lab work that you ordered reveals an iron deficiency anemia. Treat Jessica and...
Identifying Data: 28 years old female Reasons for Seeking Health Care: Urinary symptoms; burning and pain upon passing urine, brown foul smelling vaginal discharge after sexual intercourse with a boyfriend, and lower abdominal pain. History of Present Illness: The patient came to the clinic with complain of recurrent abdominal pain...
Name:R.H. S O A P Time:1.40 p.m. Date:9/30/2017 Age:30 y/o Sex:F SUBJECTIVE CC: “I have left breast pain.” HPI: Mrs. R.H. presents to the office complaining of having left breast pain starting 2 days ago. The pain radiates to left arm and neck, is dull 3-4 / 10 decreases when...
Interview Questions It is important to ask the patient the following questions: Is your pain worse at the start or the end of urination?; How severe is your pain with urination?; When did your pain with urination start?; Do you have any blood in your urine?; What are the events...
Name: A.Z. S O A P Time:12.10 p.m. Date:9/26/2017 Age:19 y/o Sex: F SUBJECTIVE CC: “I think I may be exposed to HIV.” HPI: Mrs. A.Z. presents to the office complaining of poor sleep last few weeks because she has sexual intercourse with two different partners without protection 6 weeks...
Name: M.G. S O A P Time:11.20 p.m. Date:9/14/2017 Age:35 y/o Sex: F SUBJECTIVE CC: “I have excessive menstrual bleeding.” HPI: Mrs. A.C. presents to the office complaining of having increase in numbers of days and amount of bleeding since last 3 months , and since last week she is...
Response to Ryan Burris First of all, I should admit an outstanding comprehensiveness of your post. The given case revolves around a patient suffering from the limb pain. Numerous diagnoses could be given on the basis of this symptom; however, you manage to make the right decision and suggest PAD...
Risk of Spina Bifida in the Patient and General Population Due to the relevant case of Spina Bifida (SB) detected in the child of the patient’s relative (sister), it is possible to assume that the patient should be aware of the risk of the development of Spina Bifida in her...
Name:E.A. S O A P Time:11.15p.m. Date:10/12/2017 Age:26 y/o Sex:F SUBJECTIVE CC: “Vaginal itchiness and discharge.” HPICC Vaginal itchiness Case of a 26-year-old female, that presents to the office with recurrent vaginal discharge vaginal itchiness for one week. She noticed a fishy odor with the secretions. She is worried because...
Health Issue Identification and Non-Pharmacological Interventions The clinical problem to be treated is traveler’s diarrhea (TD) (the case about Marco) that manifests itself in loose stools, fever, bloating, malaise, etc. as a result of stomach infection caused by contamination. It can be observed in people who travel outside their country...
Introduction Professional nursing practice in environments characterized by a high level of clinical complexity requires strong analytical skills. Problem-based learning can assist nursing students in developing thinking patterns that will facilitate sharp diagnostic reasoning, which is essential across all specialty areas (Zunkel, Cesarotti, Rosdahl, & McGrath, 2004). The aim of...
Discussion Subjective Data It has been long established that elevated blood pressure is linked to increased incidence of headaches and migraines (Fagernaes et al., 2015). It is expected that Mr. C will share information common for hypertensive patients with headaches: anxiety, depression, lack of physical activity, and smoking among others...
Hypertension is one of the common health issues in the USA that is associated with various negative health outcomes. It has been estimated that over 80 million Americans suffer from this disorder (Clare, 2014). Hypertension is often associated with aging, but young adults and even children can be affected as...
Subjective Data Assessment An 8-year-old child presents for continuous wheezing during the last year. The mother of the child states that they were not able to visit a doctor earlier because of the lack of money. The child as well as the mother appears disordered and anxious. During the examination,...
Introduction Important Finding Patient’s father has diabetes Patient’s mother has hypertension Maternal grandmother died of a heart attack Patient has hypertension Patient is overweight Hypertension is common in the family Daughter has type I diabetes The patient’s genetic history strongly suggests a risk of developing type II diabetes. Hypertension is...
Patient History and Physical Examination Patient Name: Mary Chief Complaint: Face rash. History of present illness: the rash has never occurred before. Past Medical History Mary has got tonsillectomy at age 9 for chronic strep throat infections. She has been healthy as an adult, never had children, never been hospitalized...
Medical Indications The patient was a young woman in the 33rd week of pregnancy who had gallstone disease and needed surgical treatment. The medical problem was acute: she was reporting all of the symptoms of the disease. The patient was suffering from strong pain in her hypochondrium and hepatic colic...
Chronic Obstructive Pulmonary Disease Smoking is the most common cause of the disorder, followed by the presence of fumes in the air as a result of poor ventilation and open fire used for cooking. The particles inhaled by the patient cause an inflammatory response and, by extension, narrowing of the...
Introduction The case under analysis presents a 76-year-old man experiencing cardiomyopathy and congestive heart failure. He has been often hospitalized. He observes problems in following the necessary diet and taking all the prescribed medicine according to the instructions. The case is even more complicated due to pitting edema, moist crackles...
Subjective Chief complaint: The patient does not have any major complaints. History of Present Illness (HPI): A patient is a middle-aged man. He does not have any health issues. A general overview of his systems was conducted. The overview showed that the patient was healthy. The patient’s past medical history...
Chronic diseases become one of the most threatening health issues all over the globe. In particular, insufficient health literacy unreasonably impacts older adults in the United States. The challenge is complicated by the fact that the aging population, being a vulnerable group, needs adequate patient-oriented education. At this point, nurses...
Identifying Data: R.M. Reasons for Seeking Health Care High fever, vomiting, and severe stomach ache. History of Present Illness The patient came to the clinic with a complaint of recurrent high fever, vomiting, and stomach aches for the last 6 or 7 months. The high fever often occurs in the...
What is the CC in this Case Study? A patient presented the chief complaint of bodily fatigue, twitch, and a possibility of fainting during some physical exercises. Besides, this disease might also influence weakness in one’s legs and constantly blurred vision. Moreover, it is essential to accent on infections that...
Additional Laboratory or Radiological Tests and Their Rationale A radiological test that should be performed is a chest x-ray with posteroanterior and lateral views. This mode is the recommended one in the assessment of typical bacterial pneumonia (Chavez et al., 2014). Diagnosis is made based on the clinical appearance and...
