Physicаl Exаm Findings: VITAL SIGNS: Temperаture: 37.2°C (98.9°F) Pulse rate: 80 bpm Respiratiоn Rate: 18/min Blооd pressure: 126/80 mmHg. Oxygen saturation: 99% on room air Weight: 79.5 kg (175 lb) Height: 182 cm (72 in) GEN: Well-developed, well-nourished female. Appears in no acute or general distress. Alert and oriented x 4, answering questions appropriately. HEENT Atraumatic, normocephalic. Ear canals clear bilaterally, TMs pearly gray with no bulging or defect noted. Nares patent, septum intact. Lips and gingiva normal in appearance, posterior pharynx without erythema or exudates. PERRLA, EOMI B/L. NECK: Neck is supple, no masses, trachea midline, no thyroid nodules, masses. No lymph node tenderness or enlargement. SKIN: No bruising, cyanosis, or pigment changes appreciated, without obvious lesions or rashes. Normal hair pattern. HEART: Regular rate, regular rhythm with normal S1, S2, without rubs, murmurs or gallops auscultated. No peripheral edema noted. No JVD. LUNGS: Clear to auscultation B/L. No adventitious breath sounds. No increased respiratory effort appreciated. No wheezing, rales, rhonchi, or stridor. PERIPHERAL VASCULAR: Capillary refill WNL throughout extremities, < 2s. No peripheral edema. Pulses 2+ and intact at DP, PT, brachial and radial B/L. No digital clubbing noted. ABD: Normoactive bowel sounds heard throughout all quadrants. Soft, non-distended abdomen without tenderness to light or deep palpation. No rebound or guarding noted. No hepatosplenomegaly noted. No abdominal bruits or pulsatile masses. No CVA tenderness elicited B/L. The bladder does not feel distended on palpation. No masses appreciated on deep palpation. GU/Rectal: Pelvic exam reveals pink, multiparous, non-friable cervix. No discharge, CMT, or bleeding from closed cervical os. No appreciable mass or deformity. Vaginal canal without blood present throughout. No inguinal LAD appreciated. Rectal exam reveals normal sphincter tone. No hemorrhoid, mass, or lesions noted externally. Hemoccult testing negative. NEURO: Pt alert and oriented x 4, following commands appropriately. Speech clear and without slurring. No facial asymmetry. Gait steady and without limp or need for assistance. Strength 5/5 in all extremities and major muscle groups, equally throughout B/L sides. No sensory deficit appreciated throughout extremities. PSYCH: Affect and mood normal. Judgment and insight intact; no confusion. No homicidal or suicidal ideation. No pressured or tangential speech. No evidence of hallucinations. Diagnostic Results: CBC WBC 8.2 RBC 4.5 Hgb: 13.2 Hct 36.9% MCV 85 MCHC 29 Platelets 300 Neutrophils 56% Lymphocytes 30% Monocytes 6% Eosinophils 3% Basophils 1% 4.0-11.0 3.9-5.1 12-16 35-45% 80-100 27-34 150-450 40-60% 20-40% 2-8% 1-4% 0.5-1% CMP Sodium 138 mmol/L Potassium 4.1 mmol/L Chloride 100 mmol/L CO2 24 mmol/L BUN 18 mg/dL Creatinine 0.9 mg/dL Glucose 114 mg/dL Calcium 9.1 mg/dL Alk phos 48 U/L ALT 20 U/L AST 19 U/L Albumin 4.4 g/dL Total Protein 7.1 g/dL Total bilirubin 0.9 mg/dL 135-145 mmol/L 3.5-5 mmol/L 96-106 mmol/L 20-30 mmol/L 6-20 mg/dL 0.6-1.3 mg/dL 60-126 mg/dL 8.5-10.2 mg/dL 20-130 U/L 4-36 U/L 8-33 U/L 3.4-5.4 g/dL 6.0-8.3 g/dL 0.1-1.2 mg/dL PT/INR PT: 11.2 INR: 1.0 PT: 11-13.5 seconds INR: 1-1.2 aPTT 25 seconds 22–39 seconds Urinalysis and microscopy Color: Yellow Appearance: Clear Leukocyte esterase: 0 Nitrites (mg/dL): 0 Urobilinogen (mg/dL) 0.9 Protein (mg/dL): 40 pH: 6.8 Blood (mg/dL): 0.250 Specific gravity: 1.01 Ketones (mg/dL): 0 Bilirubin (mg/dL): 0 Glucose (mg/dL): 0 RBC: 50/hpf WBC: None/hpf Squamous epi cells: 3/hpf Bacteria: None seen Mucus: Trace Clear to yellow Clear 0 (Negative) 0 mg/dL (Negative) 0.2-1 mg/d/L 0-20 mg/dL 4.6-8.0 0-0.02 mg/dL 1.005-1.030 0 mg/dl (Negative) 0 mg/dl (Negative) 0 mg/dl (Negative) 0-4 / hpf 0-4 / hpf 0-3 / hpf None None to trace Urine Gram Stain and Culture Preliminary gram stain reveals no bacterial growth; Final (full) culture and sensitivity results are pending No bacteria seen (gram stain); No bacterial growth (culture) Urine NAAT STI Panel(gonorrhea, chlamydia, trichomoniasis) Negative; Negative; Negative Negative; Negative; Negative 24-hour urine protein 140 mg/dL per 24 hours
HPI: Mr. Reynаud is а 23 y/о M presenting tо urgent cаre fоr evaluation of the sense that he feels like he is “dying” at times. He reports this started approximately 2 months ago. The reported sense he feels occurs during episodes in which he feels short of breath, pounding and racing heart sensation, nauseousness, and tingling throughout his extremities. Pt states that the episodes last approximately 3-5 minutes and don’t seem to occur with any specific event. These mostly occur at rest or at work and have not occurred during exercise or exertion. He states the symptoms completely resolve after 5-15 minutes. Since first starting, he has now had 4-5 episodes and for the last 5-6 weeks reports he is scared he is going to have more. He states he doesn’t want to die. He reports going to the ER last week for these symptoms and states he underwent a “heart evaluation and testing” that he was told was “fine” and that all tests were negative and was sent home to follow up with his family doctor as needed. He admits to receiving an unknown medication during his visit which made him feel better. He was not given any new medications. He notes the episodes have increased in frequency since his side hustle workload has increased on top of his restaurant job. He admits to feeling under pressure to find a “real job” by his family and admits to using his marijuana vape to help calm him down after work a few times per week. He often speaks with his sister for social support. Patient denies SI/HI, leg swelling, syncope, headaches, changes in vision, chest pain, recent injuries, weakness or numbness anywhere. Between episodes, he denies having any unusual symptoms. Medications: Melatonin 10mg PO QHS Allergies: NKDA Past Medical History: Chronic conditions: Primary insomnia (diagnosed by PCP 6 months ago) No other reported chronic conditions Pt denies hx of DVT/PE. Surgeries: R hand (ring finger) fracture repair with pin placement (2009). No other recent surgeries. Immunizations: Pt believes he is up to date on his required vaccines/immunizations. Family History: Father: alive, 56 years old. Known hx of high cholesterol Mother: alive, 55 years old. Known hx of asthma and depression Sister: alive, age 20, Known hx of anxiety, otherwise healthy Brother: alive, age 18, Known hx of traumatic brain injury after being hit by a car at age 10 Social History: Tobacco/Vape: Frequent daily use of electronic vape use (tobacco/nicotine), typically for stress relief. Pt states he does this at last 2-3 times per hour. Alcohol: Pt denies alcohol use on a routine basis. Caffeine Use: Pt does not use caffeinated products. Illicit drugs: Pt reports using a vape that contains THC/marijuana. Pt states he does this 2-3 times per week, usually after work or a busy day. Marital/Sexual: Pt is single. Reports being sexually active with two partners over the last year. States he uses condoms when sexually active. Living situation: Lives with his parents in La Jolla after graduating college to save up some money to move out on his own. Job: Works at a busy French cuisine restaurant in La Jolla. Pt states the job is demanding and stressful to ensure no mistakes are made. Reports he was almost fired last week after making a mistake with a large table order. Pt also works as a social media/lifestyle photographer on the side, which he enjoys. Hobbies: Surfing, diving, photography, prior cross-country runner in high school. Diet: Normal diet. No specific restrictions. Pt admits to eating staff meals at work when he can since they are provided free. Religion: Agnostic Sleep: Averages 3-5 hours of sleep per night ROS: Constitutional: Denies fever, chills, night sweats, unintentional weight loss or weight gain recently. Reports normal appetite. Skin: Denies hair loss, nail pitting, rashes, lesions, or skin discoloration. HEENT: Denies rhinitis, sore throat, congestion, ear pain or discharge, eye pain or change in vision, headache. Denies hearing changes, tinnitus, or nasal discharge. No lymph node swelling reported. CV/PV: See HPI. Denies chest pain or tightness, swelling or edema of lower extremities. No syncope or pre-syncope reported. Pulmonary: Admits to episodes of brief SOB as noted in HPI. Denies coughing, wheezing, hemoptysis, stridor, dyspnea, orthopnea, or pain with inspiration. GI: Admits to occasional nausea during episodes noted in HPI. Denies constipation, diarrhea, abdominal pain or distention, or vomiting. GU: Denies dysuria, increased (or decreased) urinary frequency, urgency, or hematuria. Denies urinary incontinence. No unusual vaginal bleeding or discharge. MSK: Denies trauma, muscle weakness, joint swelling or joint pain, difficulty moving any joints, arthralgias or myalgias. Neuro: Admits to episodes of tingling in all four extremities as noted in the HPI. Denies headache, dizziness or lightheadedness, dysarthria, slurred speech, or weakness. Denies seizures, tremors, or confusion. No other weakness observed. Psych: See HPI. Admits to feeling anxious about his work situation, which waxes and wanes depending on the week. Denies depression, fear of leaving his home, racing thoughts, suicidal ideation, homicidal ideation or hallucinations. Endocrine: Denies heat or cold intolerance, polyuria, polydipsia, or polyphagia. Heme/Lymph: Denies any recent or remote easy bruising or bleeding. Documenting the patient encounter: Based on the provided full patient history, identify your top suspected diagnosis. In addition to your top suspected diagnosis, please identify and list ten (10) critical pieces of information to document in this patient’s chart for this case to support your diagnosis and/or rule out any other concerning diagnoses. [PLO 5] Then, provide a brief rationale for each critical documentation item provided as to why you feel it is important and relevant to document in this case.
In аn expаnding envirоnment аpprоach, after students have studied the Family and the Schоol in grade one, the topic the child is most likely to study in grade 2 is
Which оf the fоllоwing is а goаl?
Intrо аnd Chief Cоmplаint (PLO 1) Pаtient Infо and Chief Complaint: Patient name: Trevor Connolly Patient age: 50 Gender: Male Chief complaint: “Insomnia” Care setting: Emergency Department, walk-in Additional Information: During the check-in process, this patient completed a basic patient intake form. The following information was obtained from that form: Reason for visit: Patient is complaining of difficulty sleeping for the last 2 days Past medical history: Hypertension, Depression, Hepatitis C, Lumbar back strain 3 months ago. Medication allergies: None Question 1 Identifying Aspects of the Patient History: (A.) List 10 specific historical questions that would be important to ask the patient in this case based on the information above. [PLO 1] (B.) For each question that you plan to obtain, please list one (1) reason why you would inquire about that piece of information (be specific). Note: Do not use the same reasoning more than once when answering part B of this question