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NURS 6512N: Advanced Health Assessment and Diagnostic Reasoning Week 9: Assessment of Cognition and the Neurologic SystemAssessing Neurological SymptomsScenario 2: Patient Initials: DBAge:47yoGender: Female Ethnicity: CaucasianSubjective Data:CC:Right wrist painHPI: 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: NoneAllergies:NKDAPMHx: NoneSoc Hx: Denies tobacco abuse. Denies ETOH abuse. Denies Illicit drug abuse. Single. Employed as a hairdresser full-time.Fam Hx: NoneROS: 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.
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 motionwith weakness and pain in the right wrist. No history of fractures.