A 20-year-old female presents to the college health service for… A 20-year-old female presents to the college health service for evaluation of unintentional weight loss of about 15 lbs. and increased fatigue. She has also noticed some joint pain, particularly in her wrists and knees. She has recently noticed a rash on her face and any other exposed skin after she has been in the sun. She is a junior in the nursing program at the college and thinks most of this is due to her course and clinical schedule but “just wants to be sure.” She denies any chronic health problems, takes no medications on a regular basis, and has no allergies. She states she is not in a sexual relationship right now because she “is too busy.” Her LMP was 3 weeks ago and was “normal.”ROSGeneral: fatigue, weight lossHEENT: denies headache, visual changes, eye or ear pain, nasal congestion, sore throatNeck: no lumps, swelling, stiffnessChest/Cardiac/Pulmonary: no difficulty breathing, SOB. No palpitations, cough, chest pain.GI: some decrease in appetite and occasional nausea. No vomiting, diarrhea, constipation.GU: no dysuria, frequency, urgency. Periods have been “normal.”Neuro: headaches weekly, respond to ibuprofen; some feelings of muscle weakness with pain. Pain in wrists and knees. No syncopal episodes.MSK: denies injuries, bone painSkin: rashesPEGeneral: Alert, oriented. 78-12-110/74HEENTHead: normocephalic, atraumatic; several small patches of alopeciaEyes: PERLA, mild scleral jaundiceEars: TMs pearly, (+) light reflexesNose: clearMouth/Throat: clearNeck: Supple, full ROM; no lymphadenopathyChest: Symmetric, respirations easy bilaterallyCardiac: Normal S1/S2; no murmurs heard. Peripheral pulses 2+Pulmonary: Lungs clear and equalAbdomen: Soft, non-distended and non-tender; positive bowel sounds in all quadrantsNeuro: no focal deficitsGU: deferredMSK: Mild swelling bilateral wrists & knees; some erythema noted around knees. Pain at limits of ROM in wrists & knees.Skin: erythematous, malar rash over nasal bridge and cheeks Module 2 Assignment Identify 3 potential diagnoses for this patient. List the most likely dx first.Identify data from the case that supports your diagnosis.What additional data is needed to confirm or eliminate each diagnosis? Outline the pathophysiology of this patient’s diagnosis. Based on the pathophysiology of this diagnosis, what kinds of problems might this patient have in the future? Identify long-term management considerations for this patient. What types of medications or other therapies is this patient likely to need in the future? Health Science Science NursingNUR 106
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