Our Services

Get 15% Discount on your First Order

[rank_math_breadcrumb]

right foot pain for three days. 5/10 intensity on the pain scale.

 right foot pain for three days. 5/10 intensity on the pain scale. 

CC:
right foot pain for three days. 5/10 intensity on the pain scale.

This is a 58-year-old male with PMH of HTN, HLD, GOUT, ESRD, CVA right side with Hemiplegia-wheelchair bound, HTN, CKD-4 on Dialysis 3x/week, Who presents to the office for regular follow-up. He complains of right foot pain for three days. 5/10 intensity on the pain scale, described as intermittent shooting pain, alleviated by rest and OTC medications, aggravated by mobility, pain does not radiate to another region. No trauma. The patient denies SOB, chest pain, palpitations, headaches, or dizziness. The patient has no new complaints. Urinate once a day. He is not taking medication on Tuesday, Thursday, and Saturday on dialysis.

O: VS BP: 150/100 mmHg (right arm, seated), Heart Rate: 96 bpm, Respiratory Rate: 18 breaths per minute Temperature: 98. 3°F, Spo2: 100%, Room air, Weight: 177 lbs. (BMI: 23.1 kg/m2) (dressed), Height 6ft. 5in. (Without shoes).


OBJECTIVE:


Vital Signs:
Ht(without shoes) 172 cm (5’8”). Wt. (dressed) 58.51 kg (184 lbs.) (BMI: 28.0 kg/m2) BP 120/60 mmHg (right arm seated); 125/62 mmHg (left arm, seated); with wide cuff. Heart rate (HR) 70 bpm and regular. Respiratory rate (RR) 18 bpm. Temperature (oral) 97. 9°F, Spo2: 100% Room air.


HEENT
: Positive for runny nose, watery eyes, and sore throat. Denies earache or dizziness.




Eyes:
Vision 20/20 in both eyes. Visual fields full by confrontation. Conjunctive pink; sclera white. Pupils 4 mm constricting to 2 mm. PERRLA. EOMI. Disc margins are sharp, without hemorrhage or exudate: no arteriolar narrowing or A-V nicking.


Ears:
Ear canal clear bilaterally. TM clear bilaterally; bilaterally Ear good cone of light. The cone of light is at 5 o’clock in the right ear and 7 o’clock in the left ear. Rinne test: Positive bilaterally (AC > BC). Weber midline: No lateralization. Mastoid process: No tenderness noted bilaterally.


Nose

 Mucosa pink, septum midline. No sinus tenderness. No polyps, turbinate intact, no evidence of bleeding.


Mouth: 
Oral mucosa pink. The dentition is good. Tongue midline. Tonsils 1+. Pharynx without exudates. 


Neck:
 Neck Supple. Trachea midline. The thyroid isthmus is palpable, and lobes are not felt.


Lymph Nodes:
 No cervical, axillary, or epitrochlear nodes. 


Thorax and Lungs:
  Thorax Symmetric with good expansion. Lungs resonant on percussion. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.


Respiratory
: Positive for a productive cough with yellowish sputum. Denies shortness of breath (SOB).


Cardiovascular:
 Regular rate and rhythm, heart rate 70 bpm. Crisp S1 and S2. At the base, S2 is louder than S1. At the apex, S1 is louder than S2. There are no murmurs or extra sounds.


Abdomen:
soft, non-tender + BS, no guarding.

Diagnostics:

Assessment:

Plan:

Pharmacologic:

Medications:

BENAZEPRIL HCL 40 MG TABLET: take one tablet (40 mg) by oral route once daily

METOPROLOL SUCC ER 200 MG TAB, take one tablet (200 mg) by oral route TID

LOW DOSE ASPIRIN EC 81 MG TAB, take 1 tablet (81 mg) by oral route once daily

PRAVASTATIN SODIUM 40 MG TAB: take one tablet (40 mg) by oral route once daily f

ALLOPURINOL 300 MG TABLET: take one tablet (300 mg) by oral route once daily

COLACE-T 100 MG CAPSULE, two tablets oral once daily

COLCHICINE 0.6 MG TABLET: take one tablet (0.6 mg) by oral route once daily

AMBIEN 10 MG TABLET (take one tablet (10 mg) by oral route once daily at bedtime)

Education:

Nonpharmacologic

follow-up

referral

NOTE

· Any diagnostics ordered/planned (this would be diagnostics needed)

· The patient was prescribed Polymyxin B/Trimethoprim solution one drop q 4 hours while awake
x7 days. (also enter quantity # here if controlled substance or antibiotics)

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Interprofessional Education

see attachment The purpose of this assignment is to evaluate how interprofessional education has evolved within the health care environment to support a more team-based approach to patient-centered health care. In a paper of 500-750 words, address the following points: 1. Define interprofessional education, explain how it was developed, and discuss the goals

Children and Families Clinicals Discussion 4

Weekly Clinical Experience 4 Describe your clinical experience for this week with a 10-month-old male with conjunctivitis · Did you face any challenges, any success? If so, what were they? · Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least

Children and Family Discussion 4

Approaches to Disease Management: Dermatologic Disorder Discuss Impetigo in pediatrics, a dermatologic disorder, and its treatment modalities. Submission Instructions: · Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

see attachment

MUST BE ORIGINAL WORK. 4-6 pages long. APA format. 3-5 scholarly resources from the last 5 years. On topic below.  Teaching Plan Paper (30 points) APA Paper  • Target Population: Adolescent boy ages 13-17 pertaining to mental health, 14 participants  o Who is your target audience? – include age of

NUR 620

 Patient Care After studying Module 1: Lecture Materials & Resources, discuss the following: The unlawful restraint of a patient can be a legal pitfall for the PMHNP.  K.W. was found eating hamburgers out of a Mcdonald’s dumpster and drinking water from an old water hose.  She had not taken a bath

HW

Professional Goal and Objectives: (SMART) · Professional goals and objectives are related to this course’s clinical rotation (practicum).  · Please note that the SMART goals and objectives you submit must be professional in nature. · During your clinical practicum, you will have the opportunity to work side-by-side with an expert (RN

Discussion

Module 5 Assignment PICOT Question Assignment effective strategies to decrease pediatric obesity in primary care settings.  This is certainly an area/challenge that FNPs are constantly faced with in primary care and particularly with some specific cultures or ethnic groups

Week 3 discu

General Instructions: Conflict is common in healthcare settings. Common team sources of conflict include hierarchical relationships, authority differentials, poor communication, negative or disruptive behaviors, and multigenerational interprofessional teams.    Include the following sections:  Application of Course Knowledge: Answer all questions/criteria with explanations and detail.  Describe a conflict you have encountered in your nursing

NUR509W4

DISCUSSION: The nurse practitioner (NP) is working at a health clinic in a homeless shelter during the early evening. A 48-year-old African American man approaches the practitioner and asks to have his blood pressure taken, saying that he has not had it checked “in a while”. The man appears to

NUR509CL 4

DISCUSSION: Describe your clinical experience for this week. · Did you face any challenges, any success? If so, what were they? · Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales. (CASE: R shoulder

nurse sam

Anemia Classification Instructions: For each of the scenarios below, identify the following: 1. Type of anemia a. Folate Deficiency b. Anemia of Inflammation c. Iron Deficiency Anemia d. Vitamin B12 Deficiency e. Thalassemia 2. Classification of anemia a. Microcytic-hypochromic b. Macrocytic-normochromic c. Normocytic-normochromic 3. After identifying the type and class,

nursing

To Prepare: Review resources about contextual factors. Consider how contextual factors will impact your advocacy priority.  By Day 3 of Week 4 Post a response detailing the following:  Which contextual factors will promote getting your advocacy priority on the agenda?  Which contextual factors might work against it?

nursing

To prepare: Search databases in the Walden Library and locate a peer-reviewed article from the last 5 years that uses a randomized controlled trial study design. The subject of the study may be any topic professionally relevant or interesting to your practice. You may not select an article already posted by

AMP450Effective Leadership Approaches and Models in Health Care

Effective leadership is integral to quality health care. Following global crisis, crucial leadership skills are needed to not only navigate stressful situations with the collaboration of the interprofessional health care team but also to lead with innovation and find solutions for the future.

AMP450Topic 1 DQ 2

Describe two unique challenges that health care leaders face and how leadership theories can address these challenges.

AMP450Topic 1 DQ 1

Explore the Myers-Briggs Type Indicator (MBTI) information located in chapter four of the textbook. Using the “Reflection: 16 MBTI Types at a Glance,” determine your personality and preferred behavioral leadership style. Present your discoveries and explain how your identified leadership style allows you to be a steward at the team

314Topic 1 DQ 1

Select an allied health care profession and provide a description of the jobs and services provided by that profession. Research regulatory or professional organizations that serve the profession you chose, and describe an area in which the profession seeks to improve or expand. In what other ways might the profession

314Topic 1 DQ 2

Select and describe one of the key factors that influenced the evolution of the U.S. health care delivery system to what it is today. What challenges and opportunities are still relevant? How is the selected key factor affecting health care delivery today? How might it affect future health care delivery?