3 DQ 2 NR 601
â€“ Mild â€œheartburnâ€ after eating a large meal for at least 2 years.
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.
ROS and Physical Exam:
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 doesnâ€™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.
She walks approximately
1 mile a day. She recently retired as an office manager 4 years ago.
All vaccines are current
Never had a colonoscopy
Last mammogram was 5
Has an occasional glass
of wine with dinner
Does not smoke
Cholecystectomy 20 years
Hysterectomy 10 years
Ibuprofen 200-800 mg prn
for hip pain
NR601 Week 4.2
Discussion Part Two (graded)
Vital signs: blood pressure 128/84, heart rate 80
respirations 20, temperature 98.5
height 5â€™3â€, weight 130
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
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.