Download NINA ADAMS IHUMAN CASE STUDY. CC- FATIGUE AND ARM WEAKNESS and more Exams Nursing in PDF only on Docsity! QUESTIONS AND ANSWERS NINA ADAMS IHUMAN CASE STUDY. CC- FATIGUE AND ARM WEAKNESS TESTED AND CONFIRMED A+ ANSWERS 1 iHuman – Nina Adams Student’s Name Institution of Affiliation Course Code and Name Professor Date 4 HEENT/Neck: She complains of vision problems but denies any trouble hearing or having headaches. Cardiovascular: She denies experiencing chest pain/pressure/discomfort/dizziness/palpitations. Respiratory: She complains of an early morning smoker's non-productive cough. Gastrointestinal: She denies any problems with nausea, vomiting, constipation, diarrhea, coffee grounds in her vomit, dark tarry stool, bright red blood in her bowel movements, early satiety, or bloating. Genitourinary: She denies any pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day or night, or any changes in frequency. Musculoskeletal/Osteopathic Structural Examination: She denies any problems with muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint swelling or redness, back pain, neck or shoulder pain, or hip pain. Neurologic: She complains of weakness, tingling, and numbness in her right arm and hand, but denies any dizziness, passing out, or seizures. Skin: She denies any problems with an itchy scalp, skin changes, moles, thinning hair, or brittle nails. Breast: She denies any discharge, lumps, scaly nipples, pain, swelling, or redness. Endocrine: She denies any problems with cold or heat intolerance, increased thirst, increased sweating, frequent urination, or change in appetite. Hematologic/Lymphatic: She denies any bruising, bleeding gums, nose bleeds, or other sites of increased bleeding. 5 Psychiatric: She states that things have been getting more stressful since her father had a stroke and that she has been doing a lot more to help her mother take care of their father. However, she reports that she has been coping “Ok.” Allergic/Immunologic: Her immunization is up to date with no known drug or food allergies. Objective General: 45-year-old female A and O x4, not in apparent respiratory distress, good nutritional status and well groomed. Vital Signs: Temp. 37.0 degrees Celsius, RR-18 bpm, regular and unlabored, PR-76 bpm, regular and average strength, BP-120/60 mmHg, SpaO2 98% on RA, Weight -, Height -, BMI – 21.8. Physical Examination: HEENT/Neck: The scalp is non-tender and has no lesions. The head is normocephalic, and atraumatic, with no deformities. Facial features are symmetric, non-tender temporal arteries and frontal and maxillary sinuses. The eyelids have no edema, erythema, or ptosis. The Conjunctival is pink with no discharge. Sclerae is anicteric, and the orbital area has no edema, redness, tenderness, or lesions noted. Visual acuity is standard on the right but diminished on the left (OD 20/20; OS 20/200). On ophthalmoscopic examination, the right optic disc is standard, but the left is pale and has signs of edema. The Occulomotor test is abnormal on the left with a restricted upper and medial gaze. The neck is soft, with no masses or other lesions, and non-tender. The trachea is in the midline, and there is no asymmetry, or use of accessory respiratory muscles with quiet breathing. Musculoskeletal: Normal bulk, tone, and range of motion. The patient is right-handed. She has the power of 5/5 in the upper left extremity and both lower limbs. The right-sided upper 6 extremity strength is diminished 4/5 in the hand grip, wrist extension/flexion, elbow extension/flexion, and shoulder extension/flexion. Neurological: Normal mini-mental exam. Normal tone and bulk in the muscles. Intact cranial nerves IV-XII, but cranial nerves II and III demonstrate a left-sided afferent pupillary defect. The right upper extremity (from hand to shoulder) has impaired light touch, pain perception, vibration, and position sense. The sensation is normal or intact in other parts of the body. Negative Phalen and Tinel’s signs. Investigation 1. CSF analysis 2. Brain MRI 3. Cervical spine MRI Assessment • Multiple Sclerosis Differential Diagnosis • Stroke, ischemic • Stroke, Hemorrhagic • Transient Ischemic Stroke • Nerve entrapment • Peripheral neuropathy • Hypertensive encephalopathy • R/o COPD Plan Further Assessment
