A 68 year old female presents to her PCP with C/O right neck
A 68 year old female presents to her PCP with C/O right neck pain… A 68 year old female presents to her PCP with C/O right neck pain that extends into theright shoulder and arm that started abruptly 2 days ago. She denied all forms of trauma orinjury. She also C/O headache, mostly posteriorly. She does work in the yard and gardendaily. She denies chest pain and shortness of breath. She rates the pain at 8/10, it is difficultto sleep and daily activities are interrupted. She denies numbness or tingling.VS: T:98.4, HR:78, R:17, B/P: 160/84, SAT: 98%PMH: HTN, Heart Murmur, Hyperlipidemia, OsteoarthritisAllergies: NKDAPSH: Tubal Ligation, Basal cell carcinoma, TAH/BSOSH: Married, 2 children, Never smoker, No alcohol intakeMedications: Simvastatin 20mg daily, Atenolol 25mg BIDFH: HTN, Breast Cancer, DiabetesDiscussion s:1. Is there more information needed from the patient? What history s, HPIinformation is needed?2. What type exam are you going to perform? Exam components performed? Why?3. What diagnostic testing are you going to order, if any? Give rationale andreferences4. What are your differential diagnosis? Why? Give rationale and references.5. Will you administer any treatment? In office? Prescribed?5. What is your follow up timeframe?Discussion 2LG presents back to the clinic 4 days later with increased pain in neck and right arm andnow involving the low back and upper legs. She states the pain is 10/10 starting lastevening. She states that she experienced significant reduction in pain after the Decodron5mg/ Triamcinolone 40mg injection she received last visit.1. What will you add to your history? What do you want to know?1. What will you add to your exam? Differentials?1. Will you order any diagnostics? Give rationale1. Would you order another corticosteroid injection? Prescribe oral steroids?NSAIDS? Other?Next week:LG presents back to clinic after 2 weeks with C/O return of muscle pains in right neck,shoulder, arm, blowback and legs. She states that now there seems to be some jointinvolvement in hips and knees. She woke this morning with chills, fever of 101f . The painlevel is 7/10. She states she had almost complete relief of pain after steroid injection andwhile taking the oral steroid burst/taper. Pain returned on last 2 days of steroid therapy.2. Are there any changes to differentials?3. Will any diagnostics be ordered?3. Will you make any referrals?Health Science Science Nursing NURSING 123
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