Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages to Order 5-10 Pages Description/Paper Instructions
SUBJECTIVE
Mary is a 63‐year‐old female who presents with upper midback pain that began after lifting her 3‐year‐old granddaughter 3 days ago. She says the pain began right after she lifted her grand-daughter up over her head and then placed her into the high chair. Her granddaughter weighs about 25 pounds. Mary says she has done this many times without any pain or problems in the past. Mary cares for her granddaughter during the day while her daughter is working. She describes the pain as sharp and notes that it radiates into her lower chest and around to her abdomen. Mary’s pain is constant and heavy but does wane a little bit with rest (5–7 on a 1–10 scale). It is unaffected by nonsteroidal anti‐inflammatory drugs (NSAIDs), acetaminophen, or topical rub, each of which she tried once. She feels slightly short of breath, described as “it is hard to take a full breath in, because it hurts.” She found it difficult to put on a turtleneck shirt this morning.
Mary describes her overall health as “good.” She says that she is enjoying retirement and caring for her granddaughter. She reports stable weight for the past 5–6 years; she had gained 5–10 pounds in the first 2–3 years after menopause. She identifies her usual weight as 120–125 pounds. She reports good energy and that she usually sleeps well but has not slept well since this pain began. She denies any substantive premenstrual syndrome (PMS) symptoms when she was having regular menses. She denies having had symptoms of premenstrual dysphoric disorder (PMDD).
Mary reports her usual mood as “excellent!” Mary denies moodiness, nervousness, anxiety, irritability, or feeling quick to anger. She denies feeling depressed and says, “I laugh a lot. I have loads of fun caring for my granddaughter, and my husband is always quick with a joke.” Mary denies anhedonia and says that she enjoys gardening, reading, and social activities with her husband, friends, and daughter and her family. Mary denies eating disorders. She says she has had to reduce her intake lately to keep her weight stable.
Mary denies problems with concentration, memory, or cognition. She says she uses a calendar to keep track of activities, especially appointments or play dates and preschool for her grand-
daughter. Mary reports no specific systemic complains. She denies general fatigue and says she did not have terrible hot flashes like her sister did with the change of life. She feels well.
HEENT: Mary denies problems with headaches. However, she has sinus headaches when her seasonal allergies are bothersome. Mary uses bifocals, which she has had for many years. She has annual ophthalmologic exams with her optometrist. She denies changes in hearing, smell, taste, or swallowing. She reports some dry‐eye symptoms and needs to use eye‐lubricating drops only rarely. She has seasonal allergies that cause light rhinorrhea, sneezing, and itchy eyes in the fall.
Respiratory: Mary denies cough or wheeze. She describes a sensation of being short of breath since the pain began, saying, “It is not that I can’t breathe; it is that I cannot take in a full, deep breath because it hurts.”
Cardiovascular: Mary denies prior chest pain, palpitations, dyspnea on exertion (DOE), peripheral edema, or a history of blood clots. She says that the pain she has now radiates into her lower chest but is definitely coming from her upper midback area. She denies problems with cold hands and feet. She reports being diagnosed with high blood pressure about 8 years ago. She has been treated with HCTZ, which she tolerates well.
Breast: Mary reports that she does regular self–breast exams. She usually does them at the beginning of the month when she changes the calendar to the new month. She denies any concerns or recent breast changes. She denies any discharge, pain, or tingling. She breastfed her daughter.
Gastrointestinal: Mary denies heartburn or persistent abdominal pain. She reports daily regular bowel movements, without constipation or recent changes in color, consistency, or pattern of stools. Specifically, she denies seeing any blood or experiencing fecal incontinence. She describes some pain radiating into her abdomen but again states that it is definitely coming from her upper midback.
Genitourinary: Mary reports some urgency and occasional leakage of small amounts of urine, especially with coughing or laughing. She denies urinary frequency, history of recurrent urinary tract infections, pyelonephritis, renal stones, and urine dribbling or outright incontinence. She says she does not have dysuria. She reports occasional nocturia of once or twice at night. She says this is usual for her over many years and that she goes right back to sleep after using the toilet.
Gynecological: Mary reports no abnormal Pap smears or GYN surgeries. She denies vaginal or vulvar discharge, itching, irritation, soreness, burning, abnormal bleeding, or lesions. She denies pelvic pain or rash. She reports some vaginal dryness, especially noticed with sexual activity.
Pregnancy history: Mary has been pregnant twice. She is P2, G1, TAB 1 (for fetal demise at 11 weeks). Her daughter is healthy at age 32. Mary reports that she breastfed her daughter for 13 months.
Menstrual history: Mary reports that her LMP was 11 years ago. She reports that her menses were regular, lasting for 6–7 days with 2 days of light flow, followed by 3 days of heavier flow, and then 1–2 days of light flow again. She experienced menarche at 12 years of age; and after the first few years, she had very regular periods occurring about every 28 days. Her menses remained regular right up until her last period.
Menopause: Mary reports that her experience with the transition to postmenopause was fairly smooth. She had some hot flashes during the day and rarely at night. She did not experience drenching sweats. She never took hormone therapy or other medications for her symptoms. She has some vaginal dryness, and she and her husband do use lubricant when having sexual intercourse.
Contraception: Mary reports that she used oral contraceptive pills for contraception in the past. She stopped using oral contraceptive pills after her last pregnancy; she and her husband used either male condoms or withdrawal after that. She says that she would not have minded getting pregnant again, but it never happened.
Sexual: Mary reports that she is sexually active with her husband of 35 years. She is mostly sat-isfied, but she notes that it has become harder to get adequately lubricated and that it takes longer to achieve orgasm. She reports she has had 6 lifetime partners and has been monogamous with her husband for over 38 years. They have intercourse about once a week. She reports that her desire/libido is satisfactory but is less strong than it was when she was younger. She denies dys-pareunia. She reports their usual sexual practices include initiation by her husband, cuddling and kissing, then foreplay that includes genital manipulation, and then vaginal intercourse with penile penetration. They regularly use over‐the‐counter (OTC) lubricants, due to her dryness. She says she feels good during sex and enjoys sex with her husband. She reports their relationship quality as “Wonderful. He is my partner and my best friend.” She says that, due to the pain in her upper back, she did not engage in sex last night when her husband tried to initiate.
Musculoskeletal: Mary reports that she felt good up until 3 days ago. She has had rheumatoid arthritis (RA) for many years, and it is well controlled on her current DMARD (disease‐modifying antirheumatic drug). She has used steroids for about the past 6 years (oral prednisone 5–10 mg daily depending on her symptoms) and then started DMARDs. She now takes a new DMARD, leflunomide; and she has not had a significant flare for a few years with this new medication. She does have some morning stiffness that is mostly relieved with a warm shower and movement. She gets regular exercise and is quite active in caring for her granddaughter with daily walks, often pushing the stroller, getting her in and out of the high chair, and playing with her on the swings at the park.
Endocrine: Mary denies polydipsia, polyuria, polyphagia, and symptoms of diabetes mellitus Type 2 (DMT2).
Skin/hair: Mary denies any recent skin changes or lesions of concern. She has noticed some increased dryness and wrinkles and dry/thinning hair, especially on her head. She denies hir-sutism or facial hair.
Hematologic: Mary denies any bleeding or bruising that doesn’t correlate to a specific injury. She says she is a bit surprised that there is no bruising on her back as it feels like there should be something visible.
Neurologic: Mary denies numbness, tingling, fainting, dizziness (vertigo), feeling off balance, or difficulty walking. She had some numbness in her right shoulder‐blade region the day after her pain began; that numbness has subsided.
Sleep: Mary’s usual bedtime routine includes nighttime washing and tooth brushing followed by reading for about 20 minutes. She denies using stimulants except for coffee each morning. She wakes every night to urinate and reports that she falls right back to sleep. Since her back pain began, she has had trouble sleeping. She is able to fall asleep but then awakens in pain and finds it very hard to get back to sleep because she cannot get comfortable. She usually goes to bed around 10 p.m. and falls asleep around 10:30 p.m. She gets up around 6:30 a.m. most days. She reports that she usually feels refreshed when she wakes up but has not since her back pain began.
Past medical/surgical history: Rheumatoid arthritis (RA), well controlled at present; history of oral steroid use in the past 6 years; + hypertension, controlled; + seasonal allergies (fall). Wisdom teeth excisions at age 18; TAB at age 33.
Family history: Mother: deceased from breast cancer; father: DMT2, HTN, some dementia; sister:
A+W.
Social history: Mary lives with her husband of 35 years and the family cat in a private home that they own. She is a retired elementary schoolteacher and currently provides day care for her grand-daughter while her daughter works. She reports that she enjoys caring for her granddaughter very
much and is thrilled that she can help her daughter and son‐in‐law by caring for her grand-daughter. She reports no important recent life events; the most recent was her granddaughter’s birth 3 years ago. She describes her usual day as follows: She awakes around 6:30 a.m., makes breakfast for herself and her husband, showers and dresses, greets her granddaughter and pre-pares her breakfast, reads a book with her granddaughter, and then they watch Sesame Street on TV. Some mornings they have a play date or go to the library for reading circle or music. She feeds her granddaughter lunch around noon and then settles her to nap from about 1–3 p.m. In the afternoons they might have a play date, go to the park, read, or play some games at home. Her daughter usually picks up the granddaughter around 5:30 p.m. Mary makes dinner most evenings and spends time in the evening with sewing, TV, playing cards with her husband, or doing household chores. She starts getting ready for bed around 10 p.m. She reports walking for about 1 mile most days with her granddaughter in the stroller. On the weekends she also goes to a water aerobics class. Her 24‐hour diet recall reveals: cereal with 1% milk and coffee (black) for breakfast; tuna salad on toast for lunch; grilled chicken with garden salad for dinner; and carrot sticks for an afternoon snack. She reports that she eats out about once per week and enjoys dessert on occasion. She denies use of tobacco. She reports alcohol use as 1 glass of red wine most evenings. She denies use of recreational/illicit drugs. She reports feeling safe at home and with her husband and family. She denies ever having been hit, slapped, kicked, or otherwise physically hurt by someone (except her granddaughter who occasionally will “fight” when it is time to change clothes). She denies ever being forced to have sexual activities when she did not want to. She uses seatbelts and sunblock regularly and has working smoke and carbon monoxide detectors at home. There are no guns in the home, and she denies any concerns for her granddaughter’s or her personal safety. She denies having any current concerns about HIV.
Medications: OTC antihistamines for allergies PRN; nasal spray for allergies PRN; MVI daily; calcium (when she remembers); HCTZ, 25 mg daily; glucosamine sulfate with chondroitin, 1500 mg in divided dose daily; omega‐3 supplements (fish oil), 2 g daily; leflunomide, 10 mg daily.
Allergies: NKDA, NKFA (but finds that too much yeast bothers her RA with increased morning stiffness and more joint swelling). Some “hay fever” in the fall.
OBJECTIVE
General: Appears well, but uncomfortable with slow careful movements and limited use of upper extremities; neatly dressed; appropriate affect.
Vital signs: BP: 130/78 (L) sitting; P: 74; RR: 10; weight: 130 lb; height 5 feet 5 inches; BMI 21.6.
Neck: Supple, w/o LAN. Thyroid NT, w/o palpable masses or enlargement. Carotids w/o bruits.
Limited neck AROM, especially chin‐to‐chest, due to pain.Respiratory: Clear to anterior and posterior; w/o wheezes, rales, rubs, or rhonchi. Patient unwilling to take full inhalation due to pain.
Cardiovascular: RRR, normal S1 and S2 w/o murmurs, rubs, or gallops; +pain with manual com-pression to anterior and posterior chest wall. No cyanosis, edema, or clubbing; +2 pulses bilaterally.
Breasts: Without masses, skin changes, or discharge bilaterally. No lymphadenopathy.
Abdomen: Positive for bowel sounds ×4 quadrants; soft, nondistended. NT with superficial or deep palpation; without HSM, masses, or bruits.
Back Pain 271
Spine: Good AROM at waist and for twisting with lower spine. Thoracic spine with limited AROM due to pain; +tenderness over T7 and T8.
Musculoskeletal: Positive for FAROM throughout; but limited upper spine mobility and upper extremities for full overhead movements, slight tenderness and swelling over MCP and PIP joints of BIL hands, joints w/o crepitus, no digital ulnar deviation, no swan neck or boutonniere deformities, no nodules. 5/5 motor strength, but with limited effort of bilateral upper extremities (BIL UEs).
Neurologic: CN II–XII grossly intact; gait even; DTRs 2+; Romberg negative.
CRITICAL THINKING
What are the most likely differential diagnoses in this case and why?
Which diagnostic tests are required in this case and why?
What is the plan of treatment?
What are the plans for referral and follow‐up care?
What health education should be provided to this patient?
What demographic characteristics might affect this case?
Does the patient’s psychosocial history impact how you might treat her?
Are there any standardized guidelines that should be used to treat this case? If so, what are they?
RUBRIC
QUALITY OF RESPONSE NO RESPONSE POOR / UNSATISFACTORY SATISFACTORY GOOD EXCELLENT Content (worth a maximum of 50% of the total points) Zero points: Student failed to submit the final paper. 20 points out of 50: The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. 30 points out of 50: The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately. Elements of the required response may also be lacking. 40 points out of 50: The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples. The answer is complete. 50 points: The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples. No aspects of the required answer are missing. Use of Sources (worth a maximum of 20% of the total points). Zero points: Student failed to include citations and/or references. Or the student failed to submit a final paper. 5 out 20 points: Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. 10 out 20 points: References to scholarly sources are occasionally given; many statements seem unsubstantiated. Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. 15 out 20 points: Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented. APA 6th Edition is used with only a few minor errors. There are minor errors in reference and/or citations. And/or there is some use of questionable sources. 20 points: Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented. APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. Grammar (worth maximum of 20% of total points) Zero points: Student failed to submit the final paper. 5 points out of 20: The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors 10 points out 20: The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors 15 points out of 20: The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. 20 points: The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. Structure of the Paper (worth 10% of total points) Zero points: Student failed to submit the final paper. 3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. 5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. They can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements. The student also significantly writes too large or too short of and paper 7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. 10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally, the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper. GET THIS PROJECT NOW BY CLICKING ON THIS LINK TO PLACE THE ORDER
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