nursing research article

Case 1A 36-year-old female with a medical history of Multiple Sclerosis (MS) complains of constantly feeling tired even after a period of rest or sleep. She was diagnosed with MS 3 years ago and has been on Interferon. As a wife and mother of 2 with a full-time job, she states that by the end of the day she has no energy whatsoever. The patient explains that she began noticing her lack of energy and tiredness a few months back, but it has gotten progressively worse. She also mentions that she has missed several days at work over the last 4 weeks because after getting showered and dressed, she had no energy left to go to work. Reports occasional glass of wine on the weekends, denies tobacco use or illicit drug use. She has tried some CBD oil to help with energy without relief. Reports sleeping more than eight hours a night while needing several naps throughout the day. She reports uncomfortable buzzing sensation traveling from neck down to spine with what sounds to be a Lhermitte’s sign. She denies loss of bowel or bladder. She denies fever, chills, weight loss or weight gain. She reports some nasal congestion but contributes that to allergies which she takes cetirizine 10 mg PO daily for. Reports she up to date on her pap smear, does monthly self-breast exam, denies concerns on exam. Saw her dentist and eye doctor within the last year and no issues or concerns there. Reports her mother who is alive has diabetes and hypertension. Her father and siblings are also alive without any health issues. She does have an aunt on her mother’s side who had MS as well who is currently wheelchair bound. She is alert, oriented to person, place, time and situation. Does not appear in acute distress, well-developed, slightly obese in the abdominal section. Skin is dry, warm, and intact. Normocephalic, neck supple, no thyromegaly. PERRLA about 4mm pupil size. Conjunctivae rim pale. Optic fundi examined revealed uniform red to pink color, disk is pale pink, vessels emanate from optic cup, fovea was slightly darker. Retinal vessels are free from hemorrhages or exudates. Face symmetrical. No lymphadenopathy. Oral mucosa pink and moist. Heart rate bradycardic at 56 beats per minute but regular without pauses or extra beats. Lungs diminished bilaterally but otherwise clear. Abdomen soft, non-distended, bowel sounds normoactive in all four quadrants. No suprapubic or CVA tenderness. Able to differentiate between light and deep tough, no dysmetria or ataxia, normal alternating hand movements, gait steady. Muscle tone inspected and palpated, free from fasciculation, tenderness or atrophy. Strength 5/5 in all extremities.
Case 2A 35-year-old male presents with the onset of acute low back pain. He was doing some yard work, including pulling out large bushes, when he experienced the acute onset of low back pain, radiating down the back of the left leg. Since then, the pain has worsened in intensity, and he is having difficulty bearing weight on the leg. He initially took 800 mg ibuprofen, which provided a small degree of relief, but he has not taken any medication since the problem initially occurred. The patient has no significant medical history. His general physical examination is within normal limits with regards to cardiovascular and pulmonary system. On neurological examination, he has severe pain with active movement of the lower extremity, but only minimal pain with passive movement of the lower extremity. He has a positive straight leg raise but no other neurological deficits. Denies loss of bowel or bladder or saddle anesthesia. Denies fever, chills, weight loss or weight gain. Denies headaches, dizziness, rashes or bruising. Denies history of lower back pain or previous injury to back. He is recently divorce and shares custody of three children. He reports smoking about 1 pack of cigarettes a day for 10 years but quit 5 years ago, currently vapes daily. He reports one beer with dinner, denies illicit drug use. Denies hospitalizations or surgical history. He does not get regular health maintenance and only sees primary care provider when has acute issue. He works for IT department from home and sits about 8 hours per day. He reports running at least 30 minutes daily and overall eats “healthy.” Denies family history of spine or musculoskeletal diseases or malignancy. VS in office BP 124/78, HR 79, RR 16, Temp 97.3, 100% on RA. Appears in acute distress related to pain. Rates pain 8 out of 10, described as sharp, lightening sensation.
Case 3A 19-year-old female presents with a complaint of headaches frequently. She reports that she has had them since she was a teenager, but they have become more debilitating recently. The episodes occur once or twice a month and last for up to 2 days. The pain begins in the right temple or the back of the right eye and spreads to the entire scalp over a few hours. She describes the pain as a sharp, throbbing sensation that gradually worsens and is associated with sever nausea. Several factors aggravate the pain including loud noises and movement. She has taken several over the counter medication like naproxen and acetaminophen for the pain but the only thing that makes it better is going to sleep in a dark quiet room. Reports no drug allergies but has seasonal and allergies to pet dander. A thorough history reveals her mother suffers from migraines. Last menses 4 weeks ago, is sexually active uses condoms. Currently a freshman in college. Denies alcohol, illicit drug and tobacco use. Last health visit was over the Summer, up to date on health maintenance for her age. She denies fever, chills, night sweats or neck stiffness. She denies visual changes other than photophobia. She denies chest pain, palpitations, shortness of breath or cough. She denies abdominal pain, has some nausea with the headaches but no vomiting. Denies numbness, tingling, weakness or changes in mood. Vital signs: temperature 98.5, BP 112/70, HR 62, RR 17, 99% RA, Ht. 68 inches, Wt. 151 lbs. Alert and oriented to self, place, time and situation. Appears stated age with skin warm and dry. Normocephalic, PERRL, TM gray with adequate conf of light bilaterally, no tenderness over sinuses. Mucous membranes pink and dry. No palpable masses, adenopathy or thyroid enlargement. Regular heart rate and rhythm without murmurs. No edema. Lungs clear bilaterally, no use of accessory muscles. Soft, non-tender, non-distended abdomen with normoactive bowel sounds. Normal visual acuity using Snellen chart 20/20, face symmetrical with symmetrical smile and puffing out cheeks. Weber and Rhinne test performed with normal bone and air conduction. Palate and uvula at rest are free of fasciculations and symmetry noted at test and when pt. says “ah.” Positive gag reflex. Shrug shoulders spontaneously and against resistance, hypoglossal nerve intact. Muscle tone inspected, palpated without atrophy and strength 5/5. Bicep, patellar and Achilles reflexes 2+ bilaterally with negative Babinski. Able to distinguish light and deep touch. Able to complete heel to shin, gait steady.
Review the following case studies.In a Word file construct a subjective data set for each case from the information provided.Structure the subjective data set in the format provided in your lecture materials.Submit the Word file containing your 3 subjective data sets into Canvas.
Case Studies RubricNU610 Unit 3 Assignment – Case Studies RubricCriteria Ratings PtsThis criterion is linked to a Learning OutcomeSubjective Data40 ptsHighly ProficientElements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are well written with few to no omissions or misclassifications of data from the case for all 3 cases.32 ptsProficientElements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are well written with few to no omissions or misclassifications of data from the case for 2 of the 3 cases.24 ptsMarginally ProficientElements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are well written with few to no omissions or misclassifications of data from the case for 1 of the 3 cases.16 ptsApproaching ProficiencyElements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are documented partially correct for all of the cases.8 ptsNot ProficientElements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are not documented partially correct for any of the cases.0 ptsNot EvidentAn assignment submission is not located.40 ptsTotal Points: 40
SOAP TEMPLATE FOR CASE STUDYSubjective (S):Chief Complaint (CC):HPI:PMH:Allergies:Medications:SHx:FHxHealth Promotion:ROS:
Head:EyesNeck:Throat:CV:GI:Urinary:Neurologic:Endocrine:Objective (O):Physical ExaminationHEENT:,Neck: Full ROM, no LADCV:Lungs:Abdomen:GU:PV: CRTMSK:Neuro:Diagnostic Tests:Assessment (A):Plan (P):Diagnostics:Consultation/Collaboration: