1. Identify the pertinent positives and negatives.

1. Identify the pertinent positives and negatives. 2. What additional information is needed? 3. Name three possible differential diagnosis? 4. What would your plan of care be according to guidelines? C.C. “I fell.” HPI: Ms. G is a 69 y.o. F who presented to the HU Clinical after falling at home today. Reports over the last two days has had fatigue and tremors. This morning she woke, felt unsteady with a mild headache and shaky, tried to walk to the kitchen to get a drink when she had fallen. Fall was from a standing height, landed on her buttocks on the carpeted floor. She denies hitting her head, loss of consciousness, visual changes, numbness or tingling. She denies pain. She denies fever, chills, or vomiting, but has had some nausea. Denies chest pain or SOB. She denies any aggravating factors. Allergies: NKDA Medications: Gabapentin 100 mg PO Daily Levothyroxine 75 mcg PO daily PMH: Hypothyroidism Fibromyalgia Social Hx: Divorced, lives home alone. Has 2 adult children. Retired preschool teacher. Smokes 1PPD for the last 40 years. Drinks a “few vodka tonics” a day. Denies illicit drug use. Family Hx: Mother: HTN, Father: unknown, Brother: HTN Health maintenance: Mammogram 2017, Cervical screening negative completed 2014. ROS: General: Denies fever, chills or recent ill contacts. Reports increase fatigue. Denies weight loss or weight gain. Appetite has been decreased last couple of days. Skin: Denies rashes, bruises or trauma. HEENT: Denies headache, visual changes, eye irritation, nasal drainage/congestion, difficulty swallowing. Neck: Denies swelling or stiffness. Respiratory: Denies cough, shortness of breath or wheezing. Cardiovascular: Denies chest tightness/pain. Denies swelling to lower extremities, palpitations or heart disease. GI: Denies vomiting and diarrhea. Has been having some nausea. GU: Denies dysuria, hematuria or decrease urine output. Musculoskeletal: Denies swelling or joint pain. Neuro: Denies weakness, numbness or tingling. Has noticed mild headaches and tremors worse in the morning but improves with a drink. Denies confusion. Endo: Denies increase thirst, urination, cold/hot intolerance. Psych: Denies depression/anxiety. Denies hallucinations. PE: VS: 36.7, 107, 18, 139/89, 94% RA Wt: 117 lbs, Ht: 5’7″ General: Pleasant female, appears mildly anxious, speaking in full complete sentences. Appearance kept clean. No ecchymosis, or trauma noted from fall to face. HEENT: Extraocular eye movements intact, PERRLA, moist mucous membranes, nares/oropharynx clear. No enlargement or nodules of thyroid. CV: regular rhythm, heart rate elevated 110s, S1/S2 normal Lungs: Normal work of breathing. Bilaterally clear to auscultation. ABD: Soft, non-distended, non-tender. Normoactive bowel sounds present in all four quadrants. Liver measure 10 cm by percussion. EXT: No BLE edema. +2 radial/pedal pulses bilaterally. MSK: No joint deformities or effusions. Ecchymosis 4cm x 6cm to L buttocks. Neuro: AAOx3, PERRLA +4mm, cranial nerve 2 to 12 intact. Reflexes intact +2. Upper and lower extremity strength equal 5/5. Cerebellar examine intact. Bilateral hand tremor noted with hand movements and not at rest SCIENCE HEALTH SCIENCE NURSING NU 627

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."