NURS 6512 Assignment 2 Week 4 Digital Clinical Experience (DCE) Health History Assessment IN<\/figcaption><\/figure>\nSocial History:<\/span><\/b> The patient enjoys going to clubs and drinking alcohol on occasion. Her bachelor’s degree is in accountancy. She has a loving family and friends. There will be no cigarette or marijuana use. He goes to a Baptist church.<\/span>\u00a0<\/span><\/p>\n\u00a0<\/span><\/p>\nReview of Symptoms (ROS)<\/span><\/b>\u00a0<\/span><\/h2>\nGeneral: Tina is polite, friendly, and well-organized in general. She is also well-groomed, responds well to queries, and is not depressed.\u00a0<\/span>\u00a0<\/span><\/p>\nHEENT: The patient complains of headaches when studying. He has impaired eyesight but does not use glasses. There is no runny nose or ear discharge. There is no swelling or painful throat.<\/span>\u00a0<\/span><\/p>\nNeck: There are no lymphatic problems or inflammation around the neck.\u00a0<\/span>\u00a0<\/span><\/p>\nBreasts: There is no nipple discharge or soreness in the breasts.\u00a0<\/span>\u00a0<\/span><\/p>\nRespiratory: No breathlessness, chest pain, or tightness.\u00a0<\/span>\u00a0<\/span><\/p>\nCardiovascular\/peripheral: There are no blood clots in the cardiovascular or peripheral systems.<\/span>\u00a0<\/span><\/p>\nGastrointestinal: No constipation, bowel disturbances, or watery stools. The patient feels thirsty and has an increased appetite.\u00a0<\/span>\u00a0<\/span><\/p>\nGastrointestinal: No bowel changes, constipation, or watery stool. The patient has an increased appetite and is thirsty.<\/span>\u00a0<\/span><\/p>\nGenitourinary: The patient’s periods are irregular.<\/span>\u00a0<\/span><\/p>\nMusculoskeletal: No back or muscular discomfort. Psychiatric: There are no signs of depression or hallucinations.<\/span>\u00a0<\/span><\/p>\nNeurological: There is no tingling or dizziness.<\/span>\u00a0<\/span><\/p>\nSkin: Acne-free skin with no chin hair.\u00a0<\/span>\u00a0<\/span><\/p>\nHematologic: There is no history of significant bleeding in the patient. There is no sweating, shivers, or fever.<\/span>\u00a0<\/span><\/p>\nObjective data<\/span><\/b>\u00a0<\/span><\/h2>\nVital signs: <\/span><\/b>Wt., 90 kg. BMI 31, HR 86: BP 142\/82 RR 19: Pulse oximetry 99%: T 101.1.\u00a0<\/span>\u00a0<\/span><\/p>\nDiagnostic<\/span><\/b> findings: <\/span><\/b>Wound dimensions are 2cm x 1.5cm, with a depth of 2.5mm. Serosanguinous discharge from the right ball of the foot, as well as red wound margins. There was no monitoring and no edema. Erythema around the wound is mild.<\/span>\u00a0<\/span><\/p>\nDifferential Diagnosis<\/span><\/b>\u00a0<\/span>\u00a0<\/span><\/h2>\n\n- Asthma: This respiratory disorder develops when the small airways release excessive mucus, making breathing difficult. Breathlessness, wheezing, coughing, and difficulty sleeping are all symptoms (Nakamura et al., 2020). Flu, colds, and allergens such as dust, pollen, and animal hair can all induce asthma. Drugs can be used to treat the illness. Because the patient is prone to cat dander and dust, asthma is the major diagnosis. She further complains of breathlessness and wheezing, both of which are asthma symptoms.<\/span>\u00a0<\/span><\/li>\n<\/ol>\n
\n- Local infection of the skin and subcutaneous tissue of the foot: The bacterium staphylococcus aureus is the primary cause of this illness. The disorder develops because of skin irritation generated by wounds or cuts<\/span>\u202f(Polk et al., 2021)<\/span>. When the patient reports a wound on her right leg, she may have this ailment.\u00a0<\/span>\u00a0<\/span><\/li>\n<\/ol>\n
\n- Acute pain of the foot: A fall is usually the main reason for this ailment. Pain that comes on suddenly and severely (Chung et al., 2021). The ailment may be temporary or persistent for the sufferer. The patient reported that she is in significant pain, rating it a 7 out of 10.\u00a0<\/span>\u00a0<\/span><\/li>\n<\/ol>\n
\n- Uncontrolled type 2 diabetes: This sickness causes the patient to urinate often and lose weight. She may have unmanaged type 2 diabetes since she had an excessive thirst and quit taking her diabetic medicines three years ago (Pamungkas et al., 2019). Uncontrolled diabetes might result from the same.\u00a0<\/span>\u00a0<\/span><\/li>\n<\/ol>\n
\n- Polycystic ovary syndrome: An excessive amount of androgen hormones in one’s system is the root cause of this illness. Period irregularities are a defining feature of the illness (Azziz, 2018). The woman claims to have irregular cycles every three months; thus, she most definitely has this issue.<\/span>\u00a0<\/span><\/li>\n<\/ol>\n
\u00a0<\/span><\/p>\nReferences<\/span><\/b><\/h2>\n