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Case study 1 HA
A 26 year old single female calls and requests a breast exam at your clinic.She has recently noted a rubbery large mass in her left breast and she is concerned.She has no family history of breast cancer.She does not smoke.She is currently on oral birth control pills.
What further history questions would be of value?
What kind of an exam would the provider do?
What risk factors does she have?
How would you counsel her on the phone before her appt?
Your father is 75 years old with a history of crones disease and takes amedication for this daily, no other history is noted, however you know that he had a carotid endartectomy a year ago but he said â€˜it was nothing a piece of cakeâ€.He is dancing with you at your 50th birthday party and has to stop several times and says I just need to rest a minute.Then resumes dancing a minute later.He is diaphoretic and pale.
What assessments can you make?
What questions would you ask of him or your mother as a health care informant?
What tools can you utilize when your are away from a health care facility?
Case study 4 HA
Your 15 year old is a high school wrestler. He comes home from practice after school one day and states that he has this rash on his legs.Some of the other wrestlers have one similar.It is round in shape and some irritation with it.He wonders if he got it from the toilet seats at school.
What further assessment questions would you ask?
What would you look at in terms of the rash?
What other symptoms do you think he might have?
Case study 5 HA
You are a 32 year old mother of three our oldest is 3 and the twins are 18 months old.You find one of your twins rubbing her eyes and the next morning the eyes are matted shut.You wash them out and go on about your day.Later you notice the 3 year old rubbing his eyes also.You are an RN.
What parts of the further parts of an assessment would you perform?
What history do you know that would contribute to the problem?
Chart a note SOAP style.
Case study 6 HA
You are working in a nursing home and notice one of your patients scratching under his pendulous abdomen.When you assist him with his shower is appears bright red and shiny and is moist to touch. He says it is itchy.
What history contributes to his skin condition?
What subjective data do you have?
What Objective data do you have?