1.Identify pertinent positives and negatives 2. What

1.Identify pertinent positives and negatives 2. What additional information would you need to know? 3. Name 3 differential diagnoses 4. What would your plan of care be based on guidelines? CC “My legs feel tired when I walk.” HPI: H.H. 66 y.o. M presents with a one-month history of fatigue in legs. Patient states that he first noticed this pain over one month ago when he was walking at the grocery market. He describes the pain as legs being tired. He has noticed legs appearing pale and cooler at times, no open areas. Patient reports cramping lower extremities with activity which is relieved with rest. At times will have some numbness and tingling. He has not tried anything because wasn’t sure what to do. Mr. H.H. denies CP, SOB, palpitations. PMH: HTN, pre-DM (A1c 6.1, last Summer) Surgeries Tonsillectomy at age 5. Health Maintenance: Flu and pneumonia vaccination 2 years ago. Medication: Lisinopril 10 mg PO daily. Ibuprofen 200 mg orally every 6 to 8 hours as needed for pain. Allergies: Penicillin causes rash Family History: Mother (deceased) had a history of hypertension. Father had no health problems and died at the age of 71 due to natural causes. Sister, 70 years old, with asthma and uses an Albuterol inhaler. Social History: Lives at home with his wife of 40 years. Drinks 1-2 cups of caffeinated coffee a day. Denies drinking alcohol, smoking, or using illicit drugs. ROS: General: Denies any weight loss or gain, weakness, fever, or chills. Describes overall health as good. Skin: Denies rashes, lumps, lesions, itching. Reports at times feet pale and cool to touch. Respiratory: Denies new onset of shortness of breath, cough, and wheezing. Cardiovascular: Denies any chest pain, palpitation, dyspnea, or orthopnea. Peripheral Vascular: Denies phlebitis, varicose veins, or swelling in calves. Reporting legs feeling tired with activity for 1 month now. Reports cool and pale feet at times. At times will have numbness and tingling in his feet. Currently denies pain but will have cramping with activity that is relieved with rest. Musculoskeletal: No joint pain, stiffness, swelling, redness, or difficulty in range of motion in uninjured extremities. Denies history of previous ankle injury. Denies back pain and stiffness. Neurologic: Denies headaches, visual changes, weakness in strength and confusion. Denies memory, cognition, attention or speech problems. Denies tremors. Psychiatric: Denies depression, sadness, or anxiety. Hematologic/Endocrine: Denies history of bleeding, easily bruising, and anemia. Denies history of diabetes, increase thirst/urination, thyroid problem, excessive sweating, or intolerance to heat or cold. Objective: VS 129/76 HR 62 RR 19 98% RA Wt.: 176 lbs., Ht 70″ General: Alert, oriented, and cooperative 66 years old male who appears to be in a good health. He is well groomed and is dressed appropriately for the situation. Xanthelasma bilateral eyelids. Skin: Skin pink, warm, dry, and intact without any lumps or lesions. Minimal hair growth noted to lower extremities. Nail beds pink and no cyanosis or clubbing noted. Lymph Nodes: Lymph nodes non-palpable in neck, groin, and popliteal fossa. Thorax and Lungs: Thorax symmetric bilaterally with expansion with good excursion. No abnormal curvature. Lungs resonant. Breath sound equal and clear bilaterally. Cardiovascular: Heart rate and rhythm regular. No abnormal pulsation, lifts, or jugular vein distention. Normal S1 and S2 heart sound with no S3, S4, murmurs, gallops, or rubs. Peripheral Vascular: No varicosities, ulcers, and edema noted in bilateral lower extremities. Lower extremities cap refill less than 3 seconds, uneven distribution of hair. Popliteal, posterior tibial, and dorsalis pedis pulses intact and +1 bilaterally. No redness, warmth, edema, and tenderness noted on bilateral calves or other uninjured extremities. Musculoskeletal: No joint deformities, joint instability, uneven alignment and symmetry, or complete loss of function noted in bilateral lower extremities. Full active range of motion on bilateral upper and left lower extremities. Neurological: Alert, cooperative, and oriented to person, place, and time. Muscle strength 5/5 in all extremities. Able to walk without issues. Cerebellar function intact with rapid alternating movement and point-to-point movement. Sensation intact to pinprick, light touch, position sense, and vibration. Romberg negative. Reflexes +2 in bilateral biceps, triceps, patellar, Achilles, and planter region SCIENCE HEALTH SCIENCE NURSING NU 627

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