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  • Assessment Exam PN 11

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    ASSESSMENT 11 HISTORY: Describe the history you just obtained from this patient. Include only information (pertinent positives and negatives) relevant to this patient’s problem(s). HPI: 42 YO M C/O RIGHT ELBOW PAIN. STARTED 2 DAYS AGO, WARM TO TOUCH, RED AND SWOLLEN. SHARP IN QUALITY, 6/10 INTENSITY, LASTS ALL DAY, ITS GETTING WORSE. AGGRAVATED BY MOVEMENT, ALLEVIATED BY TYLENOL AND REST. PATIENT DENIES FEVER, NUMBNESS, WEAKNESS OR RASH. PATIENT DENIES BOWEL OR BLADDER CHANGES, CHEST PAIN OR DIFFICULTY BREATHING. PATIENT IS AN AVID TENNIS PLAYER, PLAYS 2X A WEEK. ROS: NEGATIVE EXCEPT AS NOTED ABOVE ALLERGIES:DOGS AND CATS MEDICATIONS:TYLENOL PMH: NO PRIOR INCIDENTS, HOSPITALIZED FOR LESS THAN A DAY LAST YEAR WITH INFLUENZA VIRUS PSH: NONE FH: FATHER DIAGNOSED WITH HYPERTENSION, MOTHER DECEASED 5 YEARS AGO FROM A HEART ATTACK SH: DENIES TOBACCO, ETOH, OR DRUG USE. LIVES WITH BOY FRIEND, WORKS AS ADVERTISING EXECUTIVE. PHYSICAL EXAM: Describe any positive and negative findings relevant to this patient’s problem(s). Be careful to include only those parts of examination you performed in this encounter. PATIENT IS HOLDING HIS RIGHT ARM AND THE VITALS ARE WITHIN NORMAL LIMITS.. HIS BREATH SOUNDS ARE CLEAR TO AUSCULTATION BILATERALLY. HIS HEART SOUNDS ARE NORMAL S1/S2. HIS RIGHT ARM HAS RESTRCITED ROM AND UNABLE TO EXAMINE DUE TO PAIN. HIS LEFT ARM IS NONTENDER AND NOT SWOLLEN. THE MOTOR STRENGTH IS 5/5 AND SENSATION TO DULL AND PIN PRICK ARE INTACT BILATERALLY. PULSES ARE 2/4 AND SYMMETRIC BILATERALLY AND ROM ON LEFT ARM IS WITHIN NORMAL LIMITS DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient’s complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc. Diagnosis #1: LATERAL EPICONDYLITIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -RIGHT ELBOW PAIN, WARM TO TOUCH -PATIENT IS HOLDING HIS -PAIN IS SHARP, 6/10 INTENSITY RIGHT ARM -TENNIS PLAYER -ROM RESTRICTED ON RIGHT SIDE -UNABLE TO EXAMINE RIGHT ARM DUE TO PAIN Diagnosis #2: MEDIAL EPICONDYLITIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -RIGHT ELBOW PAIN, WARM TO TOUCH -PATIENT IS HOLDING HIS -PAIN IS SHARP, 6/10 INTENSITY RIGHT ARM -TENNIS PLAYER -ROM RESTRICTED ON RIGHT SIDE -UNABLE TO EXAMINE RIGHT ARM DUE TO PAIN Diagnosis #3: BURSITIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -RIGHT ELBOW PAIN, RED AND SWOLLEN –PATIENT IS HOLDING HIS -PAIN IS SHARP, 6/10 INTENSITY RIGHT ARM -TENNIS PLAYER -ROM RESTRICTED ON RIGHT SIDE -UNABLE TO EXAMINE RIGHT Diagnostic Studies: ARM DUE TO PAIN -CBC -UA -X-RAY RIGHT EPICONDYLE -CT RIGHT ELBOW -BONE DENSITY SCAN

    Judul Asli

    ASSESSMENT EXAM PN 11

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    ASSESSMENT 11 HISTORY: Describe the history you just obtained from this patient. Include only information (pertinent positives and negatives) relevant to this patient’s problem(s). HPI: 42 YO M C/O RIGHT ELBOW PAIN. STARTED 2 DAYS AGO, WARM TO TOUCH, RED AND SWOLLEN. SHARP IN QUALITY, 6/10 INTENSITY, LASTS ALL DAY, ITS GETTING WORSE. AGGRAVATED BY MOVEMENT, ALLEVIATED BY TYLENOL AND REST. PATIENT DENIES FEVER, NUMBNESS, WEAKNESS OR RASH. PATIENT DENIES BOWEL OR BLADDER CHANGES, CHEST PAIN OR DIFFICULTY BREATHING. PATIENT IS AN AVID TENNIS PLAYER, PLAYS 2X A WEEK. ROS: NEGATIVE EXCEPT AS NOTED ABOVE ALLERGIES:DOGS AND CATS MEDICATIONS:TYLENOL PMH: NO PRIOR INCIDENTS, HOSPITALIZED FOR LESS THAN A DAY LAST YEAR WITH INFLUENZA VIRUS PSH: NONE FH: FATHER DIAGNOSED WITH HYPERTENSION, MOTHER DECEASED 5 YEARS AGO FROM A HEART ATTACK SH: DENIES TOBACCO, ETOH, OR DRUG USE. LIVES WITH BOY FRIEND, WORKS AS ADVERTISING EXECUTIVE. PHYSICAL EXAM: Describe any positive and negative findings relevant to this patient’s problem(s). Be careful to include only those parts of examination you performed in this encounter. PATIENT IS HOLDING HIS RIGHT ARM AND THE VITALS ARE WITHIN NORMAL LIMITS.. HIS BREATH SOUNDS ARE CLEAR TO AUSCULTATION BILATERALLY. HIS HEART SOUNDS ARE NORMAL S1/S2. HIS RIGHT ARM HAS RESTRCITED ROM AND UNABLE TO EXAMINE DUE TO PAIN. HIS LEFT ARM IS NONTENDER AND NOT SWOLLEN. THE MOTOR STRENGTH IS 5/5 AND SENSATION TO DULL AND PIN PRICK ARE INTACT BILATERALLY. PULSES ARE 2/4 AND SYMMETRIC BILATERALLY AND ROM ON LEFT ARM IS WITHIN NORMAL LIMITS DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient’s complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc. Diagnosis #1: LATERAL EPICONDYLITIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -RIGHT ELBOW PAIN, WARM TO TOUCH -PATIENT IS HOLDING HIS -PAIN IS SHARP, 6/10 INTENSITY RIGHT ARM -TENNIS PLAYER -ROM RESTRICTED ON RIGHT SIDE -UNABLE TO EXAMINE RIGHT ARM DUE TO PAIN Diagnosis #2: MEDIAL EPICONDYLITIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -RIGHT ELBOW PAIN, WARM TO TOUCH -PATIENT IS HOLDING HIS -PAIN IS SHARP, 6/10 INTENSITY RIGHT ARM -TENNIS PLAYER -ROM RESTRICTED ON RIGHT SIDE -UNABLE TO EXAMINE RIGHT ARM DUE TO PAIN Diagnosis #3: BURSITIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -RIGHT ELBOW PAIN, RED AND SWOLLEN –PATIENT IS HOLDING HIS -PAIN IS SHARP, 6/10 INTENSITY RIGHT ARM -TENNIS PLAYER -ROM RESTRICTED ON RIGHT SIDE -UNABLE TO EXAMINE RIGHT Diagnostic Studies: ARM DUE TO PAIN -CBC -UA -X-RAY RIGHT EPICONDYLE -CT RIGHT ELBOW -BONE DENSITY SCAN

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    Assessment Exam PN 11

    Diunggah oleh

    csevideo
    ASSESSMENT 11 HISTORY: Describe the history you just obtained from this patient. Include only information (pertinent positives and negatives) relevant to this patient’s problem(s). HPI: 42 YO M C/O RIGHT ELBOW PAIN. STARTED 2 DAYS AGO, WARM TO TOUCH, RED AND SWOLLEN. SHARP IN QUALITY, 6/10 INTENSITY, LASTS ALL DAY, ITS GETTING WORSE. AGGRAVATED BY MOVEMENT, ALLEVIATED BY TYLENOL AND REST. PATIENT DENIES FEVER, NUMBNESS, WEAKNESS OR RASH. PATIENT DENIES BOWEL OR BLADDER CHANGES, CHEST PAIN OR DIFFICULTY BREATHING. PATIENT IS AN AVID TENNIS PLAYER, PLAYS 2X A WEEK. ROS: NEGATIVE EXCEPT AS NOTED ABOVE ALLERGIES:DOGS AND CATS MEDICATIONS:TYLENOL PMH: NO PRIOR INCIDENTS, HOSPITALIZED FOR LESS THAN A DAY LAST YEAR WITH INFLUENZA VIRUS PSH: NONE FH: FATHER DIAGNOSED WITH HYPERTENSION, MOTHER DECEASED 5 YEARS AGO FROM A HEART ATTACK SH: DENIES TOBACCO, ETOH, OR DRUG USE. LIVES WITH BOY FRIEND, WORKS AS ADVERTISING EXECUTIVE. PHYSICAL EXAM: Describe any positive and negative findings relevant to this patient’s problem(s). Be careful to include only those parts of examination you performed in this encounter. PATIENT IS HOLDING HIS RIGHT ARM AND THE VITALS ARE WITHIN NORMAL LIMITS.. HIS BREATH SOUNDS ARE CLEAR TO AUSCULTATION BILATERALLY. HIS HEART SOUNDS ARE NORMAL S1/S2. HIS RIGHT ARM HAS RESTRCITED ROM AND UNABLE TO EXAMINE DUE TO PAIN. HIS LEFT ARM IS NONTENDER AND NOT SWOLLEN. THE MOTOR STRENGTH IS 5/5 AND SENSATION TO DULL AND PIN PRICK ARE INTACT BILATERALLY. PULSES ARE 2/4 AND SYMMETRIC BILATERALLY AND ROM ON LEFT ARM IS WITHIN NORMAL LIMITS DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient’s complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc. Diagnosis #1: LATERAL EPICONDYLITIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -RIGHT ELBOW PAIN, WARM TO TOUCH -PATIENT IS HOLDING HIS -PAIN IS SHARP, 6/10 INTENSITY RIGHT ARM -TENNIS PLAYER -ROM RESTRICTED ON RIGHT SIDE -UNABLE TO EXAMINE RIGHT ARM DUE TO PAIN Diagnosis #2: MEDIAL EPICONDYLITIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -RIGHT ELBOW PAIN, WARM TO TOUCH -PATIENT IS HOLDING HIS -PAIN IS SHARP, 6/10 INTENSITY RIGHT ARM -TENNIS PLAYER -ROM RESTRICTED ON RIGHT SIDE -UNABLE TO EXAMINE RIGHT ARM DUE TO PAIN Diagnosis #3: BURSITIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -RIGHT ELBOW PAIN, RED AND SWOLLEN –PATIENT IS HOLDING HIS -PAIN IS SHARP, 6/10 INTENSITY RIGHT ARM -TENNIS PLAYER -ROM RESTRICTED ON RIGHT SIDE -UNABLE TO EXAMINE RIGHT Diagnostic Studies: ARM DUE TO PAIN -CBC -UA -X-RAY RIGHT EPICONDYLE -CT RIGHT ELBOW -BONE DENSITY SCAN

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    ASSESSMENT
EXAM#11


    PATIENT
NOTE

    HISTORY
–
Include
significant
positives
and
negatives
from
history
of
present
illness,
past
medical

    history,
review
of
system(s),
social
history
and
family
history.

    42
YO
M
C/O
RIGHT
ELBOW
PAIN.
STARTED
2
DAYS
AGO,
WARM
TO
THE
TOUCH,
RED
AND
SWOLLEN.

    SHARP
IN
QUALITY,
6/10
INTENSITY,
LASTS
ALL
DAY,
ITS
GETTING
WORSE.
AGGRAVATED
BY

    MOVEMENT,
ALLEVIATED
BY
TYLENOL
AND
REST.
PATIENT
DENIES
FEVER,
NUMBNESS,
WEAKNESS,
OR

    RASH.
PATIENT
DENIES
BOWEL
OR
BLADDER
CHANGES,
CHEST
PAIN
OR
DIFFICULTY
BREATHING.

    PATIENT
IS
AN
AVID
TENNIS
PLAYER,
PLAYS
2
X
A
WEEK.

    ROS:
NEGATIVE
EXCEPT
AS
NOTED
ABOVE

    ALLERGIES:
DOGS
AND
CATS

    MEDICATIONS:
TYLENOL

    PMH:
NO
PRIOR
INCIDENTS,
HOSPITALIZED
FOR
LESS
THAN
A
DAY
LAST
YEAR
WITH
INFLUENZA
VIRUS

    PSH:
NONE

    FH:
FATHER
DIAGNOSED
WITH
HYPERTENSION,
MOTHER
DECEASED
5
YEARS
AGO
FROM
A
HEART

    ATTACK.

    SH:
DENIES
TOBACCO,
ETOH,
OR
DRUG
USE.
LIVES
WITH
BOYFRIEND,
WORK
AS
ADVERTISING

    EXECUTIVE.

    

    PHYSICAL
EXAMINATION
‐
Indicate
only
pertinent
positive
and
negative
findings
related
to
the

    patient's
chief
complaint.


    GA:
PATIENT
IS
HOLDING
HIS
RIGHT
ARM

    VS:
WNL

    CHEST:
CTAB

    HEART:
RRR,
S1/S2
NORMAL

    RIGHT
ARM:
NOT
ABLE
TO
EXAMINE
DUE
TO
PAIN.
RESTRICTED
ROM

    LEFT
ARM:
NONTENDER,
NOT
SWOLLEN,
MOTOR:
STRENGTH
5/5,
SENSATION
TO
DULL
AND
PINPRICK

    INTACT
BILATERALLY,
PULSES
2/4
AND
SYMMETRIC
BILATERALLY,
ROM:
WNL
IN
LEFT
ARM.

    

    DIFFERENTIAL
DIAGNOSIS
‐
In
order
of
likelihood
(with
1
being
the
most
likely),
list
up
to
5
potential

    or
possible
diagnoses
for
this
patient's
presentation
(in
many
cases,
fewer
than
5
diagnoses
are
likely):


    

    LATERAL
EPICONDYLITIS

    MEDIAL
EPICONDYLITIS

    BURSITIS

    CUBITAL
TUNNEL
SYNDROME

    OLECRANON
FRACTURE

    


    WORK
UP

    CBC

    UA

    X‐RAY
RIGHT
EPICONDYLE

    CT
OR
RIGHT
ELBOW

    BONE
DENSITY
SCAN

    

    


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