Advanced Health Assessment week9.doc - NURS 6512N Advanced Health Assessment and Diagnostic Reasoning Week 9 Assessment of Cognition and the Neurologic

Advanced Health Assessment week9.doc - NURS 6512N Advanced...

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NURS 6512N: Advanced Health Assessment and Diagnostic Reasoning Week 9: Assessment of Cognition and the Neurologic System Assessing Neurological Symptoms Scenario 2 : Patient Initials : DB Age : 47yo Gender: Female Ethnicity: Caucasian Subjective Data: CC: Right wrist pain HPI : DB is a 47-year-old Caucasian female who presents today with pain in the right wrist that is associated with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. DB is frustrated because the pain causes her to drop her hair-styling tools. Current Medications : None Allergies: NKDA PMHx : None Soc Hx : Denies tobacco abuse. Denies ETOH abuse. Denies Illicit drug abuse. Single. Employed as a hair dresser full-time. Fam Hx : None ROS : GENERAL --AOX4. Calm Cooperative follows commands. Denies weight loss, fever, or chills. HEENT --Head: Denies headache. No loss of consciousness. No head trauma. Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears: No hearing loss, tinnitus, or drainage. Nose: Denies runny nose or congestion. Throat: Denies sore throat. Speech is clear.
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Neck --Denies any neck tenderness. No thyromegaly. No carotid bruits. No masses or tracheal deviation noted. SKIN – No rash or itching. No excoriation. CARDIOVASCULAR – No chest pain, No palpitations, No edema. RESPIRATORY – No shortness of breath, No dyspnea on excretion, No cough. GASTROINTESTINAL --No anorexia, nausea, vomiting or diarrhea. No abdominal pain. GENITOURINARY --No burning on urination. Denies frequency, hesitancy, dysuria, or incontinence. NEUROLOGICAL – Pain in right wrist with numbness and tingling in the thumb and middle finger. No headache. No dizziness, syncope, paralysis, ataxia. No change in bowel or bladder control. MUSCULOSKELETAL – No arthralgia/myalgia, no arthritis or gout. + limited range of motion with weakness and pain in the right wrist. No history of fractures.
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