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1. Case Studies Assignment Discussion Paper
Case Studies Assignment Discussion PaperUnit 5 Assignment - Case StudiesSubjective
Data Chief Complaint: “I came for annual wellness visit.” History of Present Illness: H.N is
a 29-year-old female who presents to the clinic for an annual wellness visit. She notes that
she has no current complaints or health concerns. She admits to taking Ibuprofen 400mg for
headaches occasionally. Her last hospital visit was 5 months ago when she was treated for
PCOS. Past Medical History: Patient reports she was diagnosed with PCOS 5 months ago
and was treated with Yaz birth control pills. Allergy: NKDA. Denies food or seasonal
allergies. Case Studies Assignment Discussion PaperORDER A PLAGIARISM-FREE PAPER
HERE Medication Reconciliation: Patienttakes Ibuprofen 400mg for headache occasionally.
She stopped using Yaz one month ago after achieving regular menstrual cycles. Social
History: H.N. has only just started her career as a high school teacher, and she is
simultaneously working towards earning a Master's degree in education. She is the
firstborn child of her parents and only has a younger sister. She is not married and does not
have any children. She reports that she lives alone in a rental apartment. She identifies as
heterosexual and has one partner with whom she has sexual relations. She states that she
experienced menarche at the age of 13, and her first sexual encounter occurred when she
was 16 years old. The last menstrual period occurred a week ago, with a cycle length of 28
days and a menstrual flow of 5 days. Admits to having a drink or two while they are out with
her friends occasionally. Denies ever having used cigarettes or illegal drugs. Swimming and
being involved in the activities of her church are two of her favorite hobbies. Family
History: Case Studies Assignment Discussion PaperMother- age 51, hypertensionFather-
age 56, type 2 diabetes, elevated cholesterolMaternal grandmother: deceased at age 84 of
stroke, history of hypertensionMaternal grandfather: age 85, dementiaPaternal
grandmother: age 81, elevated cholesterolPaternal grandfather: died at age 56 of a car
accident, history of obesitySister: age 23, healthy. Health Promotion: Patient does not
smoke or use illegal substances. She identifies three swimming sessions a week as part of
her routine. Consumes a significant amount of veggies as well as whole grains. Patient is
diligent about keeping her appointment for her yearly checkup on her overall wellness. She
has had all of the recommended immunizations, including the meningococcal vaccination
and the COVID vaccine, which she received this year. Booster shot for tetanus was given
within the past year. Goes for regular eye and dental exams. Case Studies Assignment
Discussion PaperBUY YOUR PAPER Review of systemsGeneral: denies fever, chills, fatigue,
or weight changesHEENT: Denies headache or history of head injury. Denies eye pain,

2. itching, or vision problems. Denies ear pain, discharge, or hearing problems. Denies sore
throat or swallowing problems.Respiratory: Denies cough, wheezing or shortness of
breathCardiovascular: Denies chest pain, palpitations or edemaGastrointestinal: Denies
abdominal pain, nausea, vomiting, diarrhea, or constipation.Genitourinary: Denies
incontinence, dysuria, polyuria, vaginal discharge, or bleeding.Musculoskeletal: Denies
muscle pain, injury, swelling or weaknessNeurological: Denies dizziness, seizures, loss of
coordination, or sense of disequilibriumPsychiatric: Denies history of depression, anxiety,
or sleep problems. Denies suicidal ideation.Integumentary: Denies rash, lesions, or scars
Case Studies Assignment Discussion PaperObjective Data Vital Signs: BP 116/71, HR 76,
RR17, Ht 5ft 4in, Wt 134 lbs, BMI 22.9. General: Pleasant appearing patient, in no acute
distress.Alert and oriented x4. Well dressed and well nourished. Clear and coherent
speech. HEENT: Normocephalic and atraumatic head with normal hair distribution. Pink
conjunctiva, white sclera, intact extraocular movement bilaterally. TMS intact and pearly
gray bilaterally. Nasal and oral mucosa pink and moist, no ulceration. Intact
dentition. Neck: No edema or lymphadenopathy. smooth thyroid, no swelling or lumps. No
skin discoloration. Respiratory: Lungs clear to auscultation bilaterally. No masses on
chest.Chest is symmetrical with respiration. Cardiovascular: S1, S2, no rubs, gallops, or
murmurs. Regular heart rate and rhythm. Capillary refill less than 3sec, No
JVD. Gastrointestinal:symmetric, soft, non-distended abdomen, no lesions or masses.
Normoactive bowel sounds in all quadrants. No guarding, tenderness, or organomegaly.
Case Studies Assignment Discussion Paper Genitourinary: No edema or masses on the
groin. Pubic hair well distributed. Normal external female genitalia. No rash, or vaginal
bleeding or discharge. Breasts: symmetrical breasts, no discreet or fixed mass. No
discolored skin on breasts or nipples. No nipple discharge, axillary lymphadenopathy or
dimpling. Musculoskeletal: Full range of motion in all extremities bilaterally, 5/5 strength.
Steady gait. No deformity. Neurological: alert and oriented to person, place, time, and
situation. Clear and coherent speech. Maintains good eye contact. Intact cranial nerve and
cerebellar function. Intact memory and thought process. Skin and Nails: Skin color
congruent with ethnic background. Afebrile to touch. No jaundice or paleness. Intact, dry,
warm and well nourished skin warm. No lesion, rash, or skin discoloration. Intact and well-
trimmed nails, no discoloration. Diagnostics:CBC, cholesterol level test, hematocrit, and
urinalysis results are all within normal limits. Case Studies Assignment Discussion
PaperInstructions Identify a friend, peer, or family member you can interview to collect
complete and comprehensive subjective and objective data sets, as though they were a new
patient in your office for an annual wellness visit. Conduct an interview and a physical
exam. Document your findings in a Word file. Structure the subjective and objective data
sets in the format provided in your lecture materials. Submit the Word file containing your
data sets into Canvas. Estimated time to complete: 1.5 hours Rubric NU610 Unit 5
Assignment - Case Studies Rubric NU610 Unit 5 Assignment - Case Studies Rubric Criteria
Ratings Pts This criterion is linked to a Learning Outcome Subjective Data 20 pts Highly
Proficient Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication
Reconciliation, Social History, Family History, Health Promotion, and ROS) are adeptly
documented (all 9 elements are correctly documented) 16 pts Proficient Elements of

3. subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social
History, Family History, Health Promotion, and ROS) are appropriately documented (at
least 7 of the 9 elements are correctly documented) 12 pts Case Studies Assignment
Discussion PaperMarginally Proficient Elements of subjective data (CC, HPI, PMH, Allergy
identification, Medication Reconciliation, Social History, Family History, Health Promotion,
and ROS) are satisfactorily documented (at least 5 of the 9 elements are correctly
documented) 8 pts Approaching Proficiency Elements of subjective data (CC, HPI, PMH,
Allergy identification, Medication Reconciliation, Social History, Family History, Health
Promotion, and ROS) are not satisfactorily documented (only 3 of the 9 elements are
correctly documented) 4 pts Not Proficient Elements of subjective data (CC, HPI, PMH,
Allergy identification, Medication Reconciliation, Social History, Family History, Health
Promotion, and ROS) are not satisfactorily documented (less than 3 of the 9 elements are
correctly documented) 0 pts Not Evident An assignment submission is not located 20 pts
This criterion is linked to a Learning Outcome Objective Data 20 pts Highly Proficient
Elements of objective data are adeptly documented and demonstrate consistency relative to
the information documented in the CC, HPI, PMH, and ROS 16 pts Case Studies Assignment
Discussion PaperORDER HEREProficient Elements of objective data are appropriately
documented and demonstrate consistency relative to the information documented in the
CC, HPI, PMH, and ROS 12 pts Marginally Proficient Elements of objective data are
satisfactorily documented but do not demonstrate consistency relative to the information
documented in the CC, HPI, PMH, and ROS 8 pts Approaching Proficiency Elements of
objective data are either not satisfactorily documented or do not demonstrate consistency
relative to the information documented in the CC, HPI, PMH, and ROS 4 pts Not Proficient
Elements of objective data are not satisfactorily documented and do not demonstrate
consistency relative to the information documented in the CC, HPI, PMH, and ROS 0 pts Not
Evident There are elements of objective data that are not provided in the assignment 20 pts
Total Points: 40 Case Studies Assignment Discussion Paper