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.

 

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. 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.

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