NR 601 Week 4 Case Study Discussions(Part-2)

Discussion Part Two (graded)

 

 

 

Physical examination:

 

 

Vital Signs:

 

Height:  5’8” Weight: 188 pounds BMI: 28.58    BP: 130/70    T: 99.0 oral    P: 72 regular    R: 24, pursed-lip breathing; Pain level-7-right shoulder

HEENT: Normocephalic, symmetric. PERRLA, EOMI, cerumen impaction bilateral ears.

 

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

LUNGS: Labored respirations; posterior RLL, LLL, RML, LML diminished breath sounds. Rhonchi right and left anterior chest.

 

 

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

 

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

 

PV: Diminished pedal pulses; hair loss noted over extremities.

 

NEUROLOGIC: Negative

 

 

GENITOURINARY:  Urinary dribbling, urgency, gets up 4 times during the night, distended bladder.

 

MUSCULOSKELETAL: Limited ROM in right shoulder. Crepitus in knees bilaterally.

 

PSYCH: Negative

 

SKIN: Negative

 

 

 

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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