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NR 601 Week 2 Case Study Discussions Physical Examination (Part-2) NEW

Discussion Part Two (graded)

Physical examination:

Vital Signs

Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8   BP 110/70 T 98.0 po P 100 R 22, non-labored; Urinalysis: Protein 2+, Glucose: 4+ HEENT: normocephalic, symmetric. Bilateral cataracts; PERRLA, EOMI; Upper and lower dentures in place a fitting well. No tinnitus NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. Thyroid non-palpable

LUNGS: Decreased breath sounds in bases bilaterally with rales, expiratory wheezing with prolonged expiratory phase noted throughout all lung fields. No costovertebral angle tenderness (CVAT) noted. Increase in AP diameter noted.

HEART: Irregularly irregular rhythm; Unable to detect S3 or murmur ABDOMEN: Normal contour; active bowel sounds all four quadrants; no palpable masses.

PV: Pulses are 2+ in upper extremities and 1+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally;

NEUROLOGIC: Achilles reflexes are hypoactive bilaterally. Vibratory perception to the 128 Hz tuning fork placed at the MTP of her great toe is absent bilaterally; She is unable to discern monofilament placement in 3 locations on her left foot and 2 places on her right foot.

GENITOURINARY: no CVA tenderness; not examined

MUSCULOSKELETAL: Heberden’s nodes at the DIP joints of all fingers and crepitus of the bilateral knees on flexion and extension with tenderness to palpation medially at both knees. Kyphosis and gait slow, but steady.

PSYCH: normal affect; her Mini-Cog Score is 3. Her PHQ-9 score is 22. SKIN: Sparse hair noted on lower legs and feet bilaterally with dry skin on her ankles and feet.

 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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NR 601 Week 1 Case Study Discussions Physical Examination (Part 2) NEW

Discussion Part Two (graded)

  Physical examination

Vital Signs:

Height:  5 feet 7 inches   Weight: 170 pounds Waist Circumference – 32 inches BP 130/84 T 98.0 po P 92 regular R 22, non-labored

HEENT: normocephalic, symmetric. Evidence of prior cataract surgery in both eyes. PERRLA, EOMI, cerumen impaction bilateral ears. Several broken teeth, loose partial plate.

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

LUNGS: Decreased breath sounds bases bilaterally, clear to auscultation HEART: RRR with regular without S3, S4, murmurs or rubs.

ABDOMEN: Bloated appearance, active bowel sounds, LLQ tenderness and 6 cm x 7 cm mass.

PV: Pulses are 2+ BL in upper and lower extremities; no edema 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. Hips: Discomfort on flexion in both hips; extensor and flexor strength symmetrical.

Knees: Left knee discomfort with weight bearing. No redness, warmth or edema. Full ROM in both knees with symmetrical extensor and flexor strength. Crepitus on extension of left knee.

Hands: No redness or swelling. Bilateral joint tenderness of the distal interphalangeal and proximal interphalangeal joints of the 2nd and 3rd digits.

Calf circumference-31 cm; Mid-arm circumference- 22 cm

PSYCH: normal affect

SKIN: Pale. Areas of healing ecchymosis: Left knee- 3 cm x 2 cm x 0 cm. Right knee -2 cm x 2.5 cm x 0 cm.

 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.

for assignment help and quiz, 

visit 

http://www.dreamassignment.com/

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