EDUC 696 Liberty University Classroom Management Questions When you look at the instructions will give you full detail on how to complete the assignment. P
EDUC 696 Liberty University Classroom Management Questions When you look at the instructions will give you full detail on how to complete the assignment. Please make sure you take a look at all of the attachments before getting started. If you have any questions about anything you may let me know. Case 1
Chief Complaint
(CC)
Case 2
“I am here today due to frequent and watery
bowel movements”
“I have pain in my belly”
“neck swelling”
A 25-year-old female presents to
A 37-year-old European American female
the emergency room (ER) with
History of Present presents to your practice with “loose stools” complaints of severe abdominal
Illness (HPI)
for about three days. One event about every pain for 2 weeks . The pain is
three hours
sharp and crampy It hurts if I run,
sit down hard, or if I have sex
A 42-year-old African American
female who refers that she has
been noticing slow and
progressive swelling on her
neck for about a year. Also she
stated she has lost weight
without any food restriction
PMH
No contributory
Patient denies
PSH
Appendectomy at the age of 14
Drug Hx
No meds
Birth control
No medication at the time
Allergies
Penicillin
NKA
NKA
Subjective
Nausea and vomiting, Last
menstrual period 5 days ago,
Fever and chills, Lost appetite Flatulence No New sexual partner about 2
mucus or blood on stools
months ago, No condoms, he
hates them No pain, blood or
difficulty with urination
Patient denies
Surgical removal of benign left
breast nodule 2 years ago
Mild difficult to shallow, Neck
feels tight, Pt states she feels
Palpitations
Objective Data
PE
B/P 138/90; temperature
B/P 158/90; Pulse 102; RR 20;
B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 99°F; (RR) 20; (HR) 110,
Temp 99.2; Ht 5,4; wt 114; BMI
5,6; wt 110; BMI 17.8
regular; oxygen saturation (PO2)
19.6
96%; pain 5/10
General
well-developed female in no acute distress,
appears slightly fatigued
acute distress and severe pain
HEENT
Atraumatic, normocephalic, PERRLA, EOMI,
arcus senilus bilaterally, conjunctiva and
sclera clear, nares patent, nasopharynx
clear, edentulous.
Atraumatic, normocephalic,
PERRLA, EOMI, conjunctiva and
sclera clear; nares patent,
Bulging eyes
nasopharynx clear, good
dentition. Piercing in her right
nostril and lower lip.
Neck
Supple
Lungs
CTA AP&L
CTA AP&L
CTA AP&L
Card
S1S2 without rub or gallop
S1S2 without rub or gallop
S1S2 without rub, Tachycardia
positive bowel sounds (BS) in all four
quadrants; no masses; no organomegaly
noted; diffuse, mild, bilateral lower quadrant
pain noted Mild diffuse tenderness.
• INSPECTION: no masses or
thrills noted; no discoloration and
skin is warm to; no tattoos or
benign, normoactive bowel
piercings; abdomen is
sounds x 4
nondistended and round
• AUSCULTATION: bowel
sounds (BS) are normal in all four
quadrants, no bruits noted
Abd
42-year-old female appears
thin. She is anxious – pacing in
the room and fidgeting, but in
no acute distress.
Diffuse enlargement of the
thyroid gland
• PALPATION: on palpation,
abdomen is tender to touch in four
quadrants; tenderness noted on
light palpation, deep palpation
reveals no masses, spleen and liver
unremarkable
• PERCUSSION: tympany heard
in all quadrants, no dullness
noted in abdominal area
GU
Non contributory
• EXTERNAL: mature hair
distribution; no external lesions
on labia
• INTROITUS: slight green-gray
discharge, no lesions
• VAGINAL: normal rugae;
moderate amount of green
discharge on vaginal walls
• CERVIX: nulliparous os with
small amount of purulent
discharge from os with positive
Non contributory
cervical motion tenderness
(CMT)
• UTERUS: ante-flexed, normal
size, shape, and position
• ADNEXA: bilateral tenderness
with fullness; both ovaries without
masses
• RECTAL: deferred
• VAGINAL DISCHARGE: green
in color
Ext
no cyanosis, clubbing or edema
no cyanosis, clubbing or edema
no cyanosis, clubbing or edema
Integument
good skin turgor noted, moist mucous
membranes
intact without lesions masses or
rashes
Thin skin, Increase moisture
Neuro
No obvious deformities, CN grossly intact IIXII
No obvious deficits and CN
grossly intact II-XII
No obvious deficits and CN
grossly intact II-XII
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