Nursing MN552 Case study

For this assignment you will be given a case study about a young lady named Sarah Smith. Review the information provided and answer the questions following. Be sure to cite your references. Look at Sarah as if she is a patient in your office seeking care. What are your immediate concerns? What needs to be done for her? Be thorough and succinct in your responses.Case Study:Sarah Smith is a 28 y/o African American female who presents to the office with c/o wound to her left foot for the past few days. States she had tripped and fell while barefoot scraping the top of her foot on the pavement. She denies any other injury from the incident. Over the past 24 hours the wound has had “smelly” drainage. Has been experiencing generalized achiness, but denies fever and chills. Did not seek medical attention at the time of injury. Has been using hydrogen peroxide to clean her wound. Is unclear of her last tetanus vaccination. Patient PMHx significant for DM II. States that she takes her medications when she remembers, and does not always check her blood sugar.PMHx:Asthma: no hospitalizations for exacerbation.DM IIPSHx:DeniesSHx:Former tobacco user: ceased smoking 2 years ago. Had smoked 1ppd x 5 yearsETOH: sociallyIllicit drugs: deniesFHx:Significant for paternal DM, otherwise unremarkableMedications:Metformin: 500mg BID po – did not take the last few daysAlbuterol MDI: 2 puffs every 6 hours prn – last use just PTASingulair: 10mg po dailyTrinessa: 1 tab po daily – last taken this amAllergies:PCN: hivesLNMP: 2 weeks ago.G0p0ROS:General: denies any weight changes, fatigue or fever; + body achesSkin: denies any rashes; + wound to left footHEENT: denies headache, head injury, dizziness, lightheadedness;Denies any vision changesDenies any hearing changes, tinnitus, vertigo, earacheDenies any nasal congestion, discharge, nose bleeds or sinus tendernessDenies any sore throat, difficulty swallowingNeck: denies any swollen glands, painBreasts: denies any pain, dischargeRespiratory: denies any dyspnea; positive cough and wheezingCV: denies any chest pain, edemaGI: denies any nausea/vomiting/diarrhea/constipation; denies bloody stoolsPV: denies claudication, swelling to LEGU: denies frequency, urgency, burning;Denies vaginal discharge, itching, soresDenies penile discharge, itching or soresMS: positive pain to left footPsych: denies nervousness, depressionNeuro: denies Headache, dizziness, vertigo, syncope, weakness; + numbness to right LEHeme: denies any easy bruisingPhysical Exam:Vital signs: 100.5 (tympanic), 162/88, 118, 22, O2 sat 95% on RAHeight: 5’5”     Weight: 250 lbs.Blood glucose: 230 (Fasting; states has not eaten yet today)patient awake, alert, oriented x 4 in NADSkin: warm, dry, color WNL. 4 cm lesion noted to anterior left foot with crusting and purulent drng; + surrounding erythema extending up 7 cm proximallyHEENT: head nontraumatic, normocephalicPupils PERRLA, EOMs intact; disc margins sharp, without hemorrhages, exudates; no AV nicking notedEars: bilateral TM with good cone of light and intactNose: mucosa pink, septum midline; no sinus tenderness appreciatedMouth: mucosa pink, moist; tongue midline; tonsils 1+ without exudateNeck: supple; trachea midline; no LADResp: regular and unlabored; lungs with end expiratory wheezing throughoutCV: RRR, S1 and S2 noted; no s3, s4 or murmur appreciatedAbdomen: soft, non-distended; Bs + x 4; no tenderness with palpation; no CVA tenderness with percussionGenitalia: deferredRectal: deferredExtremities: warm and without edema; calves supple, non-tenderPV: no LE edemaMS: + swelling to left foot; + tenderness of 2-4th left metatarsals; + left pedal pulse; CMS intact; Cap refill < 2 sec.Neuro: alert, cooperative; thought coherent; oriented x 4; cranial nerves II-XII intactQuestions:1. List your differentials for her current problems. Remember you should have at least three different differentials for each problem. Include rationale for each differential.2. At this time what medical diagnoses are you most concerned about? Do they impact other diagnoses? If so, how?3. What diagnostic images would you order? Provide your rationale. What are you trying to rule in or out?4. What laboratory work would you order? What would you anticipate to be abnormal? Provide your rationale for each.5. What is your comprehensive plan of care? Include your rationales.To view the Grading Rubric for this Assignment, please visit the Grading Rubrics section of the Course Resources.Assignment RequirementsBefore finalizing your work, you should:be sure to read the Assignment description carefully (as displayed above)consult the Grading Rubric to make sure you have included everything necessary; andutilize spelling and grammar check to minimize errors.

 

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