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NR601 week 3 discussion part 2 week 4 part 1 and 2

June 26, 2020
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Week
3 DQ 2 NR 601

S.
(Subjective)

CC
– Mild “heartburn” 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.

HPI:

Current
Medications:

PMH:

Social
Hx:

Family
Hx

Focused
ROS and Physical Exam:

ROS:

Objective:

Physical examination:

Primary
Diagnosis:

Differential Diagnosis:

Plan:


NR601 Week 4.1

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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