Health Assessment

Name: JC Age: 56

Chief Complaint (CC): Groin pain

Answer and support the following questions about the subjective data:
JC is a 56 year old male who presents to the clinic after 5 days of worsening pain and swelling in his genital region. He states that he has a fever and at night he has chills and shaking. He denies having these problems before. He had hemorrhoids with banding 3 weeks ago. "I’m a truck driver, this happens to me once in a while". He has no abdominal pain nausea vomiting, black or bloody stool. He denies dysuria or frequency. He is divorced, heterosexual and works as a truck driver. He admits to having unprotected sex occasionally.

His medical history was positive for kidney stones and hemorrhoids. He has no allergies and is taking no medications. He does not smoke and drinks beer socially on weekends with friends. His family history is significant for his mother who has type 2 diabetes.

Physical examination showed a mildly ill-appearing man that looked uncomfortable. He is awake and alert. His vital signs: Blood pressure of 158/88 mmHg, heart rate of 110, respiratory rate of 20, and temperature of 99.7 degrees. He is 5′10″ and weighs 260 lb. Head, eyes, ears, nose, and throat are normal. Lungs are clear. Heart is tachycardic with a normal s1 and s2 with no murmurs, gallops, and no rub. Abdomen is soft, distended but not tender with normal bowel sounds. His extremities have no edema, and pulses are normal bilaterally.

His genital exam show a diffuse erythema and edema of his scrotum and perineal area, that is very tender to palpation. There are multiple areas of hemorrhagic necrosis involving a large part of the scrotum but not involving the penis. His testicles are normal in size and contour and were not tender. His perirectal area is erythematous, but there was no evidence of fissures, ulcerations, or crepitus.

Laboratory data include a normal hemoglobin and hematocrit and a white blood count to 19,000 k/mm3. His chemistries reveal a sodium of 131 mEq/l and an glucose of 338 mg/dl.

Questions
What is the diagnosis? What is your differential diagnosis?

What are the potential sources?

What are the risk factors for developing this condition?

What organisms cause this condition?
What is the treatment of this condition?

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HG is a 62-year-old man with a significant history of COPD and emphysema. He has a positive PMH of frequent episodes of pneumonia. His social history includes cigarette smoking for 45 years. Identify your findings on HG and the emphysema.

What is the primary etiology of the emphysema?
What are the expected findings on inspection, palpation, percussion, and auscultation?
What are the subjective and objective findings in HG’s presentation?

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TY is a 67-year-old female patient who presents for follow-up for her hypertension and hyperlipidemia. Her PMH includes a diagnosis of aortic stenosis diagnosed 2 years ago, IBS, and a seizure disorder. Her family history includes her father, who died at age 55 years of a myocardial infarction and her mother, who is deceased, who had hypertension, diabetes, and coronary artery disease. Her social history is positive for smoking 1 PPD for 30 years; she quit 9 years ago. She is negative for alcohol and drug use. She lives in a two-bedroom condominium on one floor.

1. On examination, describe the murmur that you would hear for aortic stenosis.

2. Describe the cause of aortic stenosis. What is the cause for TY?

3. If TY’s past medical history did not include a diagnosis of aortic stenosis as well as cardiac risk factors, what other causes are there for a heart murmur?

4. If TY’s past medical history did not include a diagnosis of aortic stenosis as well as cardiac risk factors, describe a subaortic stenosis.

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Online Class Activity – Case Study # 1- Headache

Name: Laura Jackson Age: 39

Chief Complaint (CC): Headache

The nurse educator is working in a primary care setting. The next patient is a 39 year-old who is coming in for evaluation of her headaches.

Vital Signs: BP 110/80; Heart Rate 72 bpm; respirations 20 breaths per minute; temperature 98.1°F

Answer and support the following questions about the subjective data:

Determine specific questions the nurse educator could ask the patient related to the history of present illness
Discuss the specific past medical history important to know for this patient
Identify specific information that would be helpful in the patient’s family history
Identify specific information that would be needed about the patient’s social history
Explain what systems need to be included in the review of the systems and describe the specific information needed for each of the systems

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health assessment check off sheet musculoskeletal system

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