NU552 Journal: Unit 9 advanced Heath journal

Unit 9/Module 5 Journal NU552

Your Name

Date 

Patient Name: 

 Pt. Encounter Number:

Date: 

Age: 

Sex: 

SUBJECTIVE

CC: 

 "I have been feeling more tired lately and my knees have been aching when I walk."

HPI: 

Patient  reports feeling fatigued over the past 3 months, with increased joint pain, especially in his knees. He denies any recent injuries but notes that the pain worsens after physical activity. He also reports difficulty sleeping due to discomfort in his knees. He uses over-the-counter pain medication occasionally, with partial relief.

Medications:

   Tylenol 500 mg as needed for joint pain (last dose taken 2 days ago)

  Lisinopril 20 mg daily for hypertension

  Atorvastatin 10 mg daily for hyperlipidemia

Allergies: NKDA

Past Medical History: 

  Hypertension (diagnosed 10 years ago)

  Hyperlipidemia (diagnosed 5 years ago)

  Osteoarthritis (diagnosed 3 years ago)

Family History

  Father: Died at 80 from a stroke

  Mother: Died at 78 from complications of heart disease

  Brother: Alive, age 75, history of diabetes

Social History

  Retired 

  Smoked 1 pack/day for 30 years, quit 10 years ago

  Drinks alcohol socially (1-2 drinks per week)

  Lives at home with his wife, stays physically active by gardening

ROS

General: Reports fatigue but denies fever, chills, weight loss.

Peripheral Vascular: Mild swelling in the lower extremities, denies claudication or varicose veins.

Skin: Occasional dryness on arms and legs, no rashes or lesions.

Urinary: Urinating 1-2 times per night, denies dysuria or incontinence.

HEENT: Wears glasses for reading, denies recent vision changes. Hearing loss in right ear. Denies headaches, sinus issues.

Genitalia/Reproductive: DEFERRED

Neck: No swelling or stiffness, denies lumps or pain.

Musculoskeletal: Knee pain with stiffness in the morning, improves after moving.

Breasts: DEFERRED

Neurological: Denies dizziness, confusion, or falls.

Respiratory: No shortness of breath, cough, or wheezing.

Hematologic: No history of anemia or bleeding disorders.

Cardiovascular: No chest pain or palpitations. Mild peripheral edema in ankles at end of day.

Endocrine: Denies heat/cold intolerance or excessive thirst.

OBJECTIVE

Weight   180  klbs 

Ht 5’6’’

BMI 29

SPO2 96%

B/P 140/70

P 88

R 22

Temp 98

General Appearance: Alert and oriented, appears fatigued but in no acute distress.

Skin: Dryness noted on forearms and lower legs, no rashes or lesions.

HEENT: External ear structures normal, decreased hearing in the right ear. Eyes clear, no conjunctival pallor. Oral mucosa moist, no lesions.

Cardiovascular: Regular rate and rhythm, no murmurs, gallops, or rubs. Mild 1+ edema in bilateral ankles.

Respiratory: Lungs clear to auscultation bilaterally, no wheezes or crackles.

Abdomen: Soft, non-tender, bowel sounds present in all quadrants.

Breast DEFERRED

Genitourinary DEFERRED

Musculoskeletal/Spine: Tenderness over bilateral knees, range of motion limited due to pain, mild crepitus noted. No spinal tenderness.

Neurological: Cranial nerves II-XII intact. Sensation intact to light touch, motor strength 5/5 in all extremities.

Psychiatric: Appropriate affect, oriented to person, place, time, and situation.

How might diagnostic reasoning and clinical judgment be used to move toward a diagnosis in one of these systems? In your response include physical changes in older adults. Include 2-3 evidence based resources, at least one of which is a clinical guideline for a condition that may be a differential. Word count 75-100

The main goal of diagnostic thinking would be to figure out what is causing Mr. Doe's tiredness and joint pain. People over 65 often have osteoarthritis, which causes pain and stiffness in the joints, especially in weight-bearing joints like the knees (Katz et al., 2021). Based on his medical background and the fact that his joints hurt, make noise, and are limited in their range of motion, it is likely that he has arthritis. Because he has high blood pressure and peripheral swelling, it might also be a good idea to check his heart health some more to rule out heart failure. Certain tests, such as knee x-rays and basic blood work (CBC, BMP), can confirm the diagnosis and rule out other possible reasons, such as anemia or kidney failure.