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.





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.