Instructions
Review the subjective and objective data sets provided in the 3 cases. You are to construct a subjective and objective data set for each case that demonstrates your knowledge of how to construct problem focused subjective and objective data sets.
Document your 3 subjective and objective data sets in a Word file.
Estimated time to complete: 1.5 hours
Case Studies Rubric
NU610 Unit 6 Assignment – Case Studies Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeSubjective Data
20 pts
Highly Proficient
Elements 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.
16 pts
Proficient
Elements 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.
12 pts
Marginally Proficient
Elements 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.
8 pts
Approaching Proficiency
Elements 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.
4 pts
Not Proficient
Elements 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 pts
Not Evident
An assignment submission is not located.
20 pts
This criterion is linked to a Learning OutcomeObjective Data
20 pts
Highly Proficient
Elements of objective data are adeptly documented and demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS.
16 pts
Proficient
Elements of objective data are appropriately documented and demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS.
12 pts
Marginally Proficient
Elements of objective data are satisfactorily documented but do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS.
8 pts
Approaching Proficiency
Elements of objective data are either not satisfactorily documented or do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS.
4 pts
Not Proficient
Elements of objective data are not satisfactorily documented and do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS.
0 pts
Not Evident
There are elements of objective data that are not provided in the assignment.
20 pts
Total Points: 40
Case #1
Subjective:
Chief complaint: “I am here to have my Nexplanon removed”.
History of Present Illness: A twenty-three-year-old white female, G0, obese presenting for Nexplanon removal. This implant has been in place in her left arm since August of 2017, however, she desires its early removal due to unintended weight gain and increased appetite, as well as uncontrollable mood lability. She does complain of symptoms suggestive of yeast infection. She has had recurrent yeast infections to the vulva and vagina area, otherwise she is doing well.
Past Medical History: chronic headaches, dizziness, obesity, and recurrent yeast infections
Surgical History: She reports having a genitourinary surgery, she has no details. She reports having an endoscopy in November 2017 to evaluate gastritis.
Allergies: Cephalosporins – rash
Medications: No routine medications
Social History: She is single and lives at home with her parents. She works at an area convenience store as a cashier. She denies the use of tobacco products or illicit drug use. She reports she occasionally has a drink when she is out with friends. She denies any hobbies. She reports occasional intake of caffeine by way of soda and sweet tea. She reports no history of sexually transmitted infections.
Family History:
Father – 44yo, alive with no medical issues
Mother – 43yo, alive with no known medical issues
maternal grandmother – 63yo, is alive with HTN
maternal grandfather – 65yo, is alive with HTN, CVD, and PVD
paternal grandmother – deceased at 62yo secondary to a massive myocardial infarction paternal grandfather – 63yo, alive with HTN, CAD, nicotine addiction
Health Maintenance/Promotion: She reports that she is current on childhood immunizations. She reports pap smear a at the age of 21 – no abnormal cells noted. She has had no other immunizations since she finished high school. She has not seen an eye doctor in the last five years, and she does not visit a dentist on a regular basis having not been in the past three years. She does not perform regular self-breast examinations.
Review of Symptoms
General: Reports a weight gain of 27 pounds since she had her Nexplanon inserted. She denies fatigue, fever, chills, or night sweats.
Skin: Reports itching in her groin area. Denies rashes, lesions, dryness, moles, or hives. She denies nail bed color changes, breast pain, lumps, or nipple discharge.
HEENT: Denies headaches, or hair texture change. She denies blurred vision, spots, dizziness, eye redness, irritation, or drainage. She denies facial/sinus pain. Denies ear pain, hearing loss, vertigo, or drainage from ears. Denies nasal drainage, epistaxis, or difficulty with smell. Denies dry mouth, sore throat, hoarseness, or snoring. She denies mouth, tongue, or teeth pain, denies mouth ulcers, dry mouth, or chewing and swallowing difficulties. Denies bleeding gums. Denies knowledge of dental caries.
Neck: Denies neck or shoulder stiffness or swelling.
CV: Denies chest pain, chest tightness, orthopnea, and palpitations.
Lungs: Denies dyspnea, shortness of breath, cough, wheezing, bronchitis, asthma, sputum production, or hemoptysis.
GI: Denies heartburn, dysphagia, nausea, or vomiting. Denies diarrhea, constipation, black or bloody stools or changes in bowel patterns. Denies abdominal discomfort or distention. Conveys she has no food preferences and consumes a regular diet three times daily.
GU: Reports vaginal itching and a white discharge. Denies dysuria, hematuria, frequency, or abnormal bleeding. Denies flank pain. Denies history of any sexually transmitted diseases. Reports recurrent yeast infections.
PV: Denies varicose veins, temperature changes, edema, tingling, numbness, or discoloration to upper and lower extremities.
MSK: Denies mouth, neck, jaw pain, back pain, or muscle stiffness. Denies difficult walking or climbing stairs. Denies decrease in range of motion.
Neuro: Denies headache, dizziness, blackouts, tremors, weakness, numbness, speech problems, memory loss, loss of consciousness, or seizures.
Endo: Reports increase in appetite. Denies excessive thirst. Denies hot and cold intolerance.
Psych: Denies depression, anxiety, or suicidal ideations. Denies sleep disturbances.
Objective:
General: A 23-year-old morbid obese white female, healthy in appearance whom is well developed, well nourished, and well groomed. She appears in no acute distress. Ambulation noted to be normal. She is alert and orient to person, place, time and situation.
VS: Temp-97.4*F (orally), B/P-128/80 sitting-L arm, HR-97 with regular rate, RR-20, Pulse Ox-97% on Room Air at rest.
Weight – 353lbs, Height – 5′ 8″ with a BMI of 53.7
Skin: Round symmetrical face without atrophy. Warm and dry skin. Appropriate turgor with good elasticity noted, no tenting. Erythema of skin noted to bilateral inner thigh areas, below lower breast area, and between abdominal skin folds. No ulcerated areas noted. Fingernails pink.
Breast: Pendulous, no masses, no nipple discharge
HEENT:
Head: No tenderness, lesions, or evidence of trauma, evenly covered with black shoulder length hair.
Eyes: The pupils are equally round and reactive to light and accommodation at 3mm bilaterally and non-injected. Ears: No abnormality of external ears appear noted. The external auditory canals have no drainage present, the auricles are symmetrical. Tympanic membranes are pearly gray and landmarks are identifiable.
Nose: There are no external lesions, nares are patent and nasal turbinates are pink with no drainage. Midline septum. There is no frontal or maxillary sinus tenderness.
Throat: There are no mouth, lip, or gum ulcers and no bleeding gums. Visible hard palate. No throat drainage and no erythema. Tonsils visible.
Neck: Trachea is midline, no thyromegaly. There is full range of motion of neck and shoulders. There is no tonsillar, deep cervical, or posterior cervical node tenderness. No carotid bruits heard on auscultation.
CV: There is normal S1 and S2 present with a regular rhythm and rate. There are no murmurs, rubs, or gallops.There is no lower peripheral edema, clubbing, or cyanosis present and no calf tenderness.
Lungs: Symmetrical chest expansion, no dyspnea, lungs clear to auscultation. There is no chest wall tenderness.
ABD: Large, soft, no tenderness, guarding, hernias or masses, no hepato or splenomegaly present. Hyperactive bowel sounds present times four quadrants. There are no femoral or renal artery bruits auscultated.
GU: Erythema noted of skin inner and outer vaginal opening as well as the entire vulva area. There is no costovertebral tenderness.
PV: Palpable peripheral pulses. There is quick capillary refill, no clubbing noted. There is no swelling to upper or lower extremities. No varicosities. No temperature changes between upper and lower extremities.
MSK: Full ROM with normal gait and station. No deformities, normal curvature of back and no tenderness. Normal tone and motor strength.
Neuro: Motor is 5/5 throughout. Bilateral hand grip equal and strong.
Psych: Good insight and judgement, Normal mood and affect, active and alert. Normal speech, tone, and voice.
Case #2
SUBJECTIVE:
CC: “I am having pain with urinating”
HPI: A 65-year-old Asian male presenting with complaints of having pain when he voids as well as lower abdominal and back pain for the last three to four days. He states that he will get intense cramping in his abdomen and feel like he needs to void but cannot. He reports he has been drinking plenty of water and has taken a sitz bath to help with voiding. He reports that once he can void the abdominal and back pain resolves until he needs to void again. He states that he has not had any nausea or vomiting, nor has he noted any blood in the urine. He reports that the back pain is the same back pain he was having before but more intense when he has the abdominal cramping. He reports he tried the baclofen but had side effects from the medication. He reports he saw his oncologist last week and was told that his kidney function and blood counts were stable. He reports he had a CT scan of the abdomen and pelvis as well as chest done in the last 3 months and was informed everything was normal. He reports he does have a ureteral stent in place and has not seen his urologist recently.
PMH: Colon Cancer stage 3 metastasized to liver and peritoneal cavity, neuropathy that is secondary to chemotherapy, recurrent urinary tract infections, chronic constipation, degenerative joint disease lower lumbar spine
Surgical history: Right ureter stent placed 3 months ago, upper right chest port placement two years ago, appendectomy – age unknown, hernia repair with mesh 2000
Allergies: no known drug allergies
Medications:
1-Flomax 0.4mg capsules one every 12 hours for to aid in urination, lactulose 10grams/15mL twice daily for constipation, ibuprofen 200mg tablet – four every six hours as needed for back pain, Actifed over the counter (OTC) as needed for runny nose, and Oxycodone 5mg tablets – one every six hours as needed for pain.
Social history: He is divorced and lives alone. He is also retired and enjoys spending time with his family and friends. He enjoys the outdoors and fishing. He reports he was a former smoker but quit in the 1980’s. He reports occasional alcohol intake, denies illicit drug use and reports a moderate amount of caffeine intake with coffee.
Family history: He reports his father is deceased with malignant tumor of prostate. Mother is deceased with heart failure and paternal grandfather also deceased with malignant tumor of prostate.
Health Maintenance/Promotion: He reports he takes the influenza vaccination and has had two pneumococcal vaccines recently.
REVIEW of SYSTEMS:
General: A 65-year-old Asian male reporting difficulty voiding, lower abdominal and low back pain. He reports no chills, fever, night sweats or weight changes.
Skin: Denies changes to skin and denies any new lesions, rashes or dryness.
HEENT: Denies any head trauma, nodules or lesions to scalp. Denies headache, light-headedness, numbness or facial pain. He denies blurred vision, spots or tearing. He denies ear pain, hearing loss, popping sound, ear drainage or vertigo. He denies any present nasal discharge or epistaxis, He reported occasional seasonal sinusitis but has not had any problem thus far. He denies difficulty with smell or taste of food. He denies gum, lip, or mouth pain. He reports upper and lower denture set. Denies throat discomfort or difficult swallowing.
Neck: Denies neck stiffness, swelling, or nodules.
CV: Denies palpitations, tightness or chest discomfort, edema, or shortness of breath.
Lungs: Denies cough, congestion, wheezing, shortness of breath or breathing concerns.
GI: Reports abdominal pain – see HPI. Reports a mass to upper right abdomen that has not changed in size. Denies nausea, vomiting, or diarrhea. He denies gastro reflux discomfort or indigestion. He reports occasional constipation. He reports that his bowel habits have been unusual the last few days with having a normal bowel movement every four to six hours while awake and he is denying clay, tarry, or black colored stools. Denies any recent bleeding disorders or anemia. He reports his appetite has not been good the last few days.
GU: Reports lower right abdominal and flank pain, urine urgency and difficulty voiding, He reports sometimes there is burning. He denies blood in urine.
PV: Denies cramps, numbness, and tingling. Denies swelling or varicose veins. Denies discoloration to nail beds.
MSK: He reports he has noticed an unsteady gait the last few days and finds himself holding on to something when he initially gets up. He denies muscle stiffness or decrease range of motion. He denies any bony abnormalities or joint swelling. He denies use of assistance devices.
Neuro: Denies memory loss, difficult speaking, dizziness, problems with concentration, or seizures. Denies extremity tingling. Reports recent problem with walking. He denies problems with sitting or lying. He denies generalized weakness.
Endo: Denies excessive thirst or hunger, hot and cold intolerance, excessive sweating, or thyroid dysfunction.
Psych: Denies anxiety, moodiness, depression, or suicide ideations.
OBJECTIVE:
Gen: A 65-year-old Asian male whom is well-nourished, well-developed, well-groomed, ambulating normally whom appears to be chronically ill and in mild distress. He is oriented to person, place, time, and situation.
VS: Temp-97.9*F (tympanic), B/P-119/67- R arm sitting, HR-91 bpm, RR-16, Pulse Ox-95% on Room Air Weight – 190lbs, Height – 6’2″ with a BMI of 24.5.
SKIN: Symmetrical face, tan in color, skin warm and dry, with good elasticity skin turgor noted to return on top of right hand, multiple discolored spots and bruising noted to lower forearms. There are no open lesions or rashes present to forearms.
HEENT: He is bald with no lesions, nodules or deformities to scalp. Bilateral eyes equally round at 2mm with pupils reactive to light, white scleral and clear conjunctiva with no swelling, no ptosis noted, and extraocular movement is present. There is no frontal or maxillary tenderness. External ear structures are normal with clear canals and normal tympanic membranes and landmarks easily identified. Normal nasal mucosa, no obstruction to turbinate’s, no external lesions, and no septal deviation. There is no nasal drainage. The lips are moist and pink with no lesions present, no lesions at gums and no mouth ulcers. The tongue is symmetric, midline uvula, no erythema to posterior pharynx. Midline trachea as well as thyroid, no swelling present and no tenderness on palpation. Neck is supple, no cervical lymphadenopathy or tenderness bilateral, and no supraclavicular lymphadenopathy.
CV: Regular rate and rhythm with S1 and S2 present, no murmurs, rubs, or gallops and no carotid bruits. No lower extremity edema.
Lungs: Chest movement symmetric, clear bilateral breath sounds, good air exchange, no rales, rhonchi, or wheezing. No axillary adenopathy.
ABD: Bowel sounds active and normal x 4 quads, soft, non-distended, no costovertebral angle (CVA) tenderness. There is a small mass noted at the upper right quadrant with mild tenderness in lower abdomen bilaterally. There is no rebound tenderness or guarding. The liver and spleen are palpable and non-tender. No renal bruits. Patient declined rectal exam.
GU: Omitted
PV: No edema and no discoloration noted to lower extremities. No varicose veins. Radial, femoral, popliteal, and pedal pulses present and strong. There is no discoloration of nail beds.
MSK: There was a slow irregular gait noted on moving from chair to exam table. However, there was normal motor strength and muscle tone. His bilateral hand grip is strong and equal as well as leg pushes. No erythema. There is lumbar tenderness present, and negative straight leg. There are no masses felt on lumbar region. There is no shoulder drooping noted.
Neuro: He does not appear to be anxious or agitated. There are no tremors present. He can move all extremities symmetrical, finger to nose is intact. Reflexes present to patellar, biceps, triceps, and Achilles deep tendon. He reveals normal speech, tone, and concentration.
Diagnostic Tests: Urinalysis, Dipstick with results of moderate leukocytes, moderate amount of bilirubin, and trace of blood. Negative for nitrite, ketones, protein, and glucose, pH 7.0, specific gravity 1.005, urobilinogen 1.3, amber in color, clear
Case #3
SUBJECTIVE:
CC: “I am having black stool and tiredness”.
HPI: A 68-year-old white male presenting with complaints of black stool for the past two to three days whom brought a sample into clinic today. He is also complaining of feeling “sluggish and fatigued”. He reports no bad smell noted with stool or diarrhea. He became concerned when he noted a red ring forming when the stool “hit the water”. He had some musculoskeletal discomfort a couple weeks ago for which he was prescribed Lodine. He reports he took it for one week and then discontinued the use of due to problems resolving. He reports an uncomfortable feeling in the RUQ at times describing it as just an achy feeling such as gas and relieved with movement. He reports no dyspepsia or GERD. He reports no exacerbating factors. He reports taking no OTC medications for relief. He reports he had a colonoscopy in six months ago with the result indicating some diverticulosis but no polyps. The stool brought in is dark and Heme positive.
PMH: Chicken pox as a youth, hyperlipidemia and hypertension
Allergies: NKDA
Medications: He reports taking Amlodipine 2.5mg tablets daily for hypertension and an occasionally daily multivitamin for men. He reports he has not had to take any medication for hyperlipidemia for the past eight months as he has controlled it with his diet.
Surgical history: Reports orthopedic surgery in January 2014 for dislocated left shoulder, from an incident with a tractor rolling over
Social history: Married with and self employed as a pastor and co-owner in the new local ambulance service. He has two adult sons in their 30s. He reports he does not smoke nor has he ever, does not consume alcohol, does not use illicit drugs nor has he ever. Reports heavy intake of caffeine with coffee four to five cups daily.
Family history:
Wife – 67 yo, alive with hypertension and seasonal allergies
Son – 36yo, alive with ulcerative colitis
Father deceased at 79 with CVA
Mother deceased at 87 with CHF
Health Maintenance/Promotion: He reports he believes his childhood immunizations were received once he was an adult. Received influenza vaccine last flu season. Had T-dap in 2017. He follows up with his family physician yearly and with cardiology as needed. Has received the Hep B vaccine series in 2017. He had a yearly TB screening in February 2019 which was negative. Received Pneumococcal vaccine at age 65. He reports he received the zoster vaccine at age 62 on his birthday. He wears glasses with bifocals with the last exam being February 2019. He had dental exam September 2020. Received colonoscopy six months ago. Does not exercise regularly. He is in the process of building his new home.
REVIEW of SYSTEMS:
General: Denies fever, chills, night sweats, or weight change.
Skin: Denies skin rashes, lesions, dryness, or itching, reports scar to left shoulder.
HEENT: Denies headaches, migraines, head trauma, nodules to scalp. He reports frontal hair loss has been over the past 20 years with recent changes to hair texture or fingernails. Denies light-headedness, reports occasional dizziness upon standing for the past few days but quickly resolves. Denies any facial pain or numbness. Denies eye discharge, spots, or double vision. Denies cataracts. Reports eye dryness with use of artificial tears occasionally.
Denies ear pain or drainage. Reports hearing loss in both ears. Denies nasal discharge, epistaxis or difficulty with smell. Denies throat pain or difficult swallowing. Denies tongue or gum disorder. Reports full upper and lower denture set. Denies jaw pain.
Neck: Denies pain, lumps, or neck stiffness.
CV: Denies shortness of breath, dyspnea on exertion, chest discomfort, tightness, palpitations, irregular heartbeat, murmurs, or edema. Denies orthopnea.
Lungs: Denies cough, wheezing, inability to take deep breath, or hemoptysis.
GI: Reports uncomfortable feeling to RUQ at times. Denies dyspepsia or reflux disease. Denies abdominal distention, nausea or vomiting. Denies constipation or diarrhea. Reports black stools with red color. Denies excessive hunger or thirst.
GU: Denies dysuria, hematuria, urinary frequency, decrease stream, or urgency. Denies flank pain or history of kidney stones.
PV: Denies extremity swelling, tingling, or numbness. Denies calf tenderness. Denies bleeding disorders.
MSK: Denies joint or back pain, denies muscle problems. Denies arthritis. Denies unsteady gait or decrease in range of motion.
Neuro: Denies sensory problems, weakness, stroke, seizures, tremors, or numbness. Denies problems with walking or standing for periods of time. Denies history of falls. Denies memory loss.
Endo: Denies hot or cold intolerance.
Psych: Denies tension, nervousness, depression, anxiety, or suicidal ideations.
OBJECTIVE:
General: A 68-year-old, well nourished, well-groomed polite white male with clear spoken words and strong thought process with current and remote memory, decision, and cognitive making unimpaired. He is alert and oriented to person, place, time and situation, in no acute distress.
VS: TEMP – 97.2, B/P – 129/83 sitting (L arm), P – 73, RR- 18, O2SAT – 99% (Room Air),
Height – 5ft 6in, Weight – 202lbs, BMI – 32.6.
SKIN: Warm and dry, face symmetrical pale in color, skin turgor with slight tenting noting lasting longer than three seconds. No discolored spots, lesions, or rashes present to face, neck or lower forearms.
HEENT: Clean cut gray colored hair well managed with thinning to crown and frontal areas, no palpable nodules or deformities to scalp. No maxillary tenderness. Masseter and temporal muscle strength noted to be equal upon smile. Some skin looseness noted around mouth creases. Use of glasses noted. Eyes equally round and reactive to light with bilateral pupil size at 2mm, white scleral and clear conjunctiva, ptosis noted bilateral otherwise external structures appear normal. No periorbital edema, extraocular movement evident using pen and air H. Bilateral external auditory canals free from drainage, tympanic membranes with no redness or bulging, landmarks are visible bilateral. There is bilateral hearing loss noted with soft whisper voice. Nasal turbinates are clear, no lesions or bleeding, no septum deviation, no obstruction. Mucus membranes moist and pink, no ulcers noted to gums, the gums and tongue are moist and pink with proper movement, full set of dentures are noted. No exudate, lesions, or erythema noted to throat, uvula is midline. Trachea and thyroid are midline, neck supple and non-tender, no bruits, no submandibular, anterior cervical nodes, or posterior cervical nodes palpated. No shoulder drooping.
CV: Normal S1 and S2 with regular rate and rhythm, no murmurs, rubs, or gallop rhythms. PMI mid clavicular line.
Lungs: Bilateral symmetric chest excursions with normal appearing chest wall. Clear bilateral breath sounds with no rales, rhonchi, or wheezing anteriorly or posteriorly. No retraction or signs of respiratory difficulty.
ABD: Soft, large, non-tender, non-distended abdomen with hyperactive bowel sounds times four quadrants, no ascites, no epigastric tenderness, no hernia’s or masses palpable, no hepatomegaly, flank tenderness, or costovertebral angle tenderness. No renal bruits.
GU: Omitted
PV: No lower extremity edema or discoloration. No noticeable deformities. Radial and pedal pulses strong, equal, and regular. No clubbing noted.
MSK: No CVA tenderness, no defects or deformities noted. There is ability to bend and extending back and waist. Good upright posture positioning and alignment present. There is full range of motion noted. Equal bilateral hand grips strong.
Neuro: Gait is normal. Deep tendon reflexes 2/4 symmetric triceps, biceps, BR, and ankle. Motor 5/5 throughout, sensory intact with cranial nerves 2-12 intact. Good tone, moves all extremities without difficult.
Psych: Good mood and affect noted. Good speech and voice. No agitation or anxiousness present at visit.
Diagnostic Tests:
1- Hemocult = positive
2- H/H revealing 12.3/37 and Platelet count of 269
