NR 601 Week 3 Case Study Discussions(Part-2)

Discussion Part Two (graded)




Physical examination:



Vital Signs:


Height:  5’0”   Weight: 150 pounds BMI: 29.3   BP: 120/64    T: 98.0 oral  P: 68 regular    R: 16, non-labored


HEENT: Normocephalic, symmetric. Evidence of prior cataract surgery


in both eyes. PERRLA, EOMI, cerumen impaction bilateral ears.


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


LUNGS: Clear to auscultation


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


ABDOMEN: Normal contour; active bowel sounds, LLQ tenderness.


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


evidence of peripheral neuropathy.






MUSCULOSKELETAL: Gait fluid and steady. No muscle atrophy or


asymmetry. Full ROM all joints. Strength 5/5 and equal bilaterally. Joint swelling in fingers both hands.


PSYCH: Flat affect; patient declined to answer PHQ-9 and GDS


SKIN: Grossly intact without rashes or ecchymosis.




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.