Reference no: EM133555725

Homework: Advance Nursing Assessment

Introduction

For this homework, you will be given a case study. Review the information provided and answer the questions. Be sure to cite your references. Look at the case study as if the subject is a patient in your office seeking care. What are your immediate concerns? What needs to be done for them? Be thorough and succinct in your responses. Your submission must be in SOAP note format.

Case study

Journal Details

Introduction

Case Study/SOAP Note:

Julia King is a 50y/o white female who presents to the office with c/o wound to her left foot for the past few days. States she tripped and fell while barefoot, scraping the top of her foot on the pavement. She denies any other injury from the incident. Over the past 24 hours, the wound has had "smelly" drainage. Has been experiencing some numbness, tingling, and pain, but denies fever and chills. Did not seek medical attention at the time of injury. Has been using hydrogen peroxide to clean her wound. Her last tetanus shot was 15 years ago. Patient PMHx significant for DM II. States that she takes her medications when she remembers, and does not always check her blood sugar.

PMHx:

Asthma: no hospitalizations for exacerbation.

DM II

PSHx:

Denies

SHx:

Smokes 1 pack of cigarettes per day for 5 years.

ETOH: socially

Illicit drugs: denies

FHx:

Mother 71 y/o with a history of diabetes and obesity

Father 72 y/o with a history of HTN

Brother 51 alive and well

Sister 48 with a history of HTN and diabetes

No family history of colon, ovarian, or uterine cancer

No history of CAD or PVD

Medications:

Metformin: 500mg BID po - did not take the last few days

Albuterol MDI: 2 puffs every 6 hours prn - last used 3 days ago

Singulair: 10mg po daily

Allergies:

PCN: hives and facial swelling

LNMP: N/A

G2p2

ROS:

General: denies any weight changes, fatigue, or fever; + body aches

Skin: denies any rashes; + wound to left foot

HEENT: denies headache, head injury, dizziness, lightheadedness; denies any vision changes; denies any hearing changes, tinnitus, vertigo, earache; denies any nasal congestion, discharge, nose bleeds or sinus tenderness; denies any sore throat, difficulty swallowing

Neck: denies any swollen glands, pain

Breasts: denies any pain, discharge

Respiratory: denies any dyspnea; positive cough and wheezing

CV: denies any chest pain, edema

GI: denies any nausea/vomiting/diarrhea/constipation; denies bloody stools

PV: denies swelling in face, hands. No history of leg cramps or past clots in extremities. States has swelling in left foot

GU: denies frequency, urgency, burning; denies vaginal discharge, itching, sores

MS: denies any weakness, numbness, erythema, twitching, or pain. No h/o of backaches or fx's. No joint pain, tenderness, or history of head trauma. Positive for left foot pain

Psych: denies nervousness, depression

Neuro: denies Headache, dizziness, vertigo, syncope, weakness; + numbness to right LE

Heme: denies any easy bruising

Physical Exam:

Vital signs:

1) 5 (tympanic), 180/100, 90, 22, O2 sat 95% on RA
2) Height: 5'5"
3) Weight: 250 lb
4) Blood glucose: 230 (Fasting; states has not eaten yet today)

Patient awake, alert, oriented x 4 with no apparent distress (NAD)

Skin: warm, dry, color WNL. 4 cm lesion noted to anterior left foot with crusting and purulent drainage; + surrounding erythema extending up 7 cm proximally

HEENT: head nontraumatic, normocephalic

Pupils PERRLA, EOMs intact; disc margins sharp, without hemorrhages, exudates; no AV nicking noted

Ears: bilateral TM with good cone of light and intact

Nose: mucosa pink, septum midline; no sinus tenderness appreciated

Mouth: mucosa pink, moist; tongue midline; tonsils 1+ without exudate

Neck: supple; trachea midline; without any lymphadenopathy

Resp: regular and unlabored; lungs with end expiratory wheezing throughout

CV: RRR, S1 and S2 noted; no s3, s4 or murmur appreciated

Abdomen: soft, non-distended; BS + x 4; no tenderness with palpation; no CVA tenderness with percussion

Genitalia: deferred

Rectal: deferred

Extremities: warm and dry with edema to left foot; calves supple, non-tender

PV: No swelling noted to hands, feet or face. Positive swelling to left foot

MS: + swelling to left foot; + tenderness of 2nd-4th left metatarsals; + left pedal pulse; Cap refill < 2 sec.

Neuro: alert, cooperative; thought coherent; oriented x 4; cranial nerves I-XII intact

Task

Address the following items:

Question I. List your differentials for her current problems. Remember you should have at least three different differentials for each problem. Include rationale for each differential.

Question II. At this time, what medical diagnoses are you most concerned about? Do they impact other diagnoses? If so, how?

Question III. What diagnostic images would you order? Provide your rationale. What are you trying to rule in or out?

Question IV. What laboratory work would you order? What would you anticipate to be abnormal? Provide your rationale for each.

Question V. What is your comprehensive plan of care? Include your rationales.