Contact us:
+1 (520) 226-8615
Email:
[email protected]
NURS 6541 HEENT Case Senario
NURS 6541 HEENT Case Senario
You see a 2-month-old for a well-child visit. She is breastfed and nurses every 2 to 3 hours during the day, but her mother reports she is not nursing as vigorously as before. She sleeps one 4-hour block at night. Birth weight was 7 pounds 5 ounces. Weight gain over the last 2 weeks reveals gain of 5 ounces per week. Physical examination reveals the following: HEENT exam is benign, lung sounds are clear, a new III/VI systolic ejection murmur is noted along the left lower sternal border, cap refill is brisk, skin is pink and moist, and abdominal exam is benign.
Questions
Post an explanation of the differential diagnosis for the patient in the case study you selected. Explain which is the most likely diagnosis for the patient and why. Include an explanation of unique characteristics of the disorder you identified as the primary diagnosis. Then, explain a treatment and management plan for the patient, including appropriate dosages for any recommended treatments. Finally, explain strategies for educating patients and families on the treatment and management of the respiratory, cardiovascular, and/or genetic disorder.
NURS 6541 HEENT Case Senario
Review of systems
Gen: Has no fever, night sweats, heat intolerance, weakness or fatigue.
Head: No migraine headaches reported.
ENT: No visual changes, eye pain, hearing loss, tinnitus, vertigo, ear pain, ear discharge, epistaxis, nasal discharge, sinusitis, teeth problems, abnormal taste, sore throat, or speech difficulty
Neck: Denies neck swelling, pain, stiff neck, goiter, or masses, nodes.
Cardiopulmonary: Patient indicates they have not witnessed any instances of cough, dyspnea, wheezing, hemoptysis, chest pain, palpitations, orthopnea, murmurs, edema, claudication, syncope, hypertension.
GI: There have been no changes to the patients eating habits. He has tested negative for n/v, hematemesis, melena, dysphagia, heartburn, flatulence, abdominal pain, jaundice, change in bowel habits, diarrhea, constipation, hematochezia, or rectal pain.
GU: He also has been cleared of dysuria, frequency, nocturia, hematuria, urgency incontinence or polyuria.
MS: On the other hand, he has reported no backache, joint pain, stiffness. Gait is normal and steady.
Heme/Skin: Patient insists they have had no bleeding, bruising, anemia. Denies changes, pruritis, rash, or changes in hair.
Neuro: No indication of seizures, paralysis, muscle weakness, parasthesia, sensation changes.
Psych: Thought content: no SI/HI or psychotic symptoms; Associations: intact; Orientation: x 3; Mood and affect: euthymic and full and appropriate.
Physical assessment
Vital Signs:
47 Height: inches
Weight: 129lbs
Temp: 37 0C.
RR: 16
BP: 120/59
Pulse: 79 BPM
Appearance: Slender, Latino male who appears his age and no distress observed. He is well groomed and dressed to impress.