06 Feb MS: + R Shoulder Joint pain, +Joint Sw

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 3 Discussion

Diagnostic Reasoning and Advanced Physical Assessment

MODULE 3 CASE STUDY

BJ is a 10 yr old female of Hispanic origin who presents to your exam room with an adult Hispanic male that identifies himself as her uncle. He states that BJ has hurt her Right arm after falling down the steps the day before. He states she did NOT loss consciousness or injury her head. The providers asks BJ, “How did you fall down the steps?” BJ looks down and softly states, “I just tripped and feel:. Both speak with broken English.

PMI: No hospitalization or Surgeries. Immunization History is unknown.

Medications: None Allergies: None

FH: Parents Living Mother age 24 Father age 30, No Siblings

SH: Both parents work cleaning in the hotel industry. BJ is “home schooled” by her aunt.

ROS:

General: NEG weight loss or gain NEG fatigue, NEG fever

HEENT: NEG for headache, congestion, nasal drainage, vision problems, throat pain

Cardiac: NEG for chest pain, palpitations, swelling, loss of consciousness

Resp: NEG Dyspnea, Neg for cough, wheezing, NEG PND

GI: NEG Nausea, Neg for Vomiting, Diarrhea, dysphagia, pain, anorexia

MS: + R Shoulder Joint pain, +Joint Swelling, + for falls

HEME: + for bruising NEG for bleeding, Neg night sweats

ENDO: Neg for thirst, heat or cold intolerance

NEURO: NEG dizziness, Neg for confusion, numbness, aphasia

PSYCH: NEG for memory loss, Neg for nervousness, suicidal ideation