NR 601 Week 1 Case Study Discussions (Part 2)

Discussion Part Two (graded)

 

 

 

Physical examination

 

 

Vital Signs:

 

Height:  5 feet 7 inches   Weight: 170 pounds Waist Circumference – 32 inches BP 130/84 T 98.0 po P 92 regular R 22, non-labored

 

HEENT: normocephalic, symmetric. Evidence of prior cataract surgery in both eyes. PERRLA, EOMI, cerumen impaction bilateral ears. Several broken teeth, loose partial plate.

 

NECK: Neck supple; non-palpable lymph nodes; no carotid bruits.

 

LUNGS: Decreased breath sounds bases bilaterally, clear to auscultation

HEART: RRR with regular without S3, S4, murmurs or rubs.

 

ABDOMEN: Bloated appearance, active bowel sounds, LLQ tenderness and 6 cm x 7 cm mass.

 

PV: Pulses are 2+ BL in upper and lower extremities; no edema

NEUROLOGIC: Negative

 

GENITOURINARY: no CVA tenderness

 

MUSCULOSKELETAL: gait fluid and steady. No muscle atrophy or asymmetry. Full ROM all joints. Strength 5/5 and equal bilaterally.

Hips: Discomfort on flexion in both hips; extensor and flexor strength symmetrical.

 

Knees: Left knee discomfort with weight bearing. No redness, warmth or edema. Full ROM in both knees with symmetrical extensor and flexor strength. Crepitus on extension of left knee.

 

Hands: No redness or swelling. Bilateral joint tenderness of the distal interphalangeal and proximal interphalangeal joints of the 2nd and 3rd digits.

 

Calf circumference-31 cm; Mid-arm circumference- 22 cm

 

PSYCH: normal affect

 

SKIN: Pale. Areas of healing ecchymosis: Left knee- 3 cm x 2 cm x 0 cm. Right knee -2 cm x 2.5 cm x 0 cm.

 

 

 

Discussion Part Two:

 

 

Summarize the history and results of the physical exam. Discuss the differential diagnosis and rationale for choosing the primary diagnosis. Include one evidence-based journal article that supports your rationale and include a complete treatment plan that includes medications, possible referrals, patient education, ICD 10 Codes, and plan for follow-up.

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