NURS 6512 CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS Patient initial:S.M Age: 48 years old Gender: Male  CC: Bilateral Foot Pain 

NURS 6512 CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS

Patient initial:S.M Age: 48 years old Gender: Male 

CC: Bilateral Foot Pain 

HPI 

S.M is a 48-year-old Hispanic male present to the facility with complaints of discomfort in her toes and the left foot, as well as heel of the right foot tingling and numbness over the previous two weeks. He is worried about his life since the pain forces him to drop his work equipment. The patient states that he is unable to bear weight. In the right wrist, the pain is assessed at a 37 out of 10. When he engages in physical activity, the pain is intensified. Nevertheless, relaxing and using medications including Ibuprofen 800mg PO as required and Tylenol 325mg PO as appropriate will help to alleviate the pain. 

Current Medications for NURS 6512 CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS Patient

Ibuprofen 800mg PO as required for pain 

Multivitamin PO daily 

Tylenol 500mg PO as needed for pain  

Allergies 

No known drug or environmental allergies 

 PMH 

Type 2 Diabetes Mellitus 

PSH 

No surgical history 

Sexual/Reproductive History: Heterosexual; sexually active 

Personal/Social History: Married, denies cigarette smoking, alcohol, and illicit drug use 

Immunization History: Patient’s immunizations up to date; Influenza vaccine 2020; Last Tdap 11/2017 

Significant Family History: 

Mother: History of obesity  

Father: History of diabetes 

Paternal grandmother: died age 80 due to hypertension  

Paternal grandfather died age 86 from cardiac arrest; history of dementia 

Maternal grandmother died age 75 from heart attack; history of breast cancer  

Maternal grandfather died age 72 from throat cancer 

Lifestyle: S.M lives at home with his 40 years old wife. He works 9 hours a day at a workshop. He has a primary care physician and goes for his monthly checkups. He denies mental health problems. He denies exposure to domestic violence. 

Review of Systems: 

General: Denies experiencing headaches, migraines or insomnia 

HEENT: Head: Atraumatic and Normocephalic,. Eyes: no double vision or vision loss. ENT: the oral mucosa seems moist; Denies hearing loss or problems 

Neck: No pain or discomfort; Trachea midline Breasts:  

Respiratory: No history of SOB, or past TB illnesses.  

Cardiovascular/Peripheral Vascular: ; No chest pain or discomfort; Denies heart palpitation 

Gastrointestinal: No appetite loss or changes or weight gain. Denies vomiting, nausea, diarrhea, or constipation 

Genitourinary: Denies incontinence or frequency on urination. 

Musculoskeletal: pain in her toes and left foot, with tingling and numbness in the heel of the right foot  

Neurological: Denies history of seizures. 

Skin: Intact, warm and dry. Denies open wounds or rashes. 

Objective Data 

Vital signs: Temp 97.9 oral; BP 122/45 MAP 70 Right arm sitting; HR 77; RR 16 non-labored; O2 99% room air; Wt.: 60kg; Ht: 5’5”; BMI: 26.4 

General: Patient alert and oriented x4 with no acute distress. He is a well-nourished and developed man who appears his stated age. 

HEENT: Pupils respond equally to light. He is not jaundiced or pale. Moist Oral mucosa. No pharyngeal erythema. 

Neck: There is no neck elevation. No carotid swelling, or bruit. 

Chest/Lungs: is adequate bilateral air entry. Bilaterally clear lung sounds. No coughing or wheezing.  

Heart/Peripheral Vascular: Ha uniform rhythm and rate . No gallop, murmur, rub. Regular peripheral circulation 

Abdomen: stomach is soft and nontender. Bowel sounds present and regular. Recent known bowel movement 1 days ago 

Genital/Rectal: Deffered 

Musculoskeletal: Has full ROM. No found swelling or deformities. Right foot strength 3/5 and Left toe abduction 2/5 

Neurological: Alert and oriented with