NR 601 Week 7 Case Study Discussion Health Promotion, Health Protection, Disease Prevention, and Treatment Considerations in End-Of-Life Care (Part-2)

Discussion Part Two (graded)

 

 

 

Physical examination:

 

Vital Signs: Height:  6’0   Weight: 140 pounds; BMI: 19.0   BP: 156/84  P: 84 regular R: 20

 

HEENT: normocephalic, symmetric PERRLA, EOMI; poor dentition

NECK: left neck supple; non-palpable lymph nodes; no carotid bruits. Limited ROM

 

LUNGS: rhonchi in anterior chest bilaterally.

 

HEART: S1 and S2 audible; regular rate and rhythm

 

ABDOMEN: active bowel sounds all 4 quadrants; Normal contour; RUQ tenderness; liver palpable

 

NEUROLOGIC: negative

 

GENITOURINARY: negative

 

MUSCULOSKELETAL: negative

 

PSYCH: PHQ-9 is 15

 

SKIN: oral mucosa irritated-stomatitis

 

 

 

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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