NR 601 Week 8 Case Study Discussions Physical Examination

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. NR 601 Week 8 Case Study Discussions Physical Examination

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. NR 601 Week 8 Case Study Discussions Physical Examination

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. NR 601 Week 8 Case Study Discussions Physical Examination

Discussion Part One (graded)

You are seeing S.F., a 74-year-old. Hispanic male in the office this morning for difficulty breathing.

Background:

S.F. presents with increased dyspnea on exertion that has become progressively worse over the last 3 days. You observe that he is using pursed lip breathing as he explains his chief complaint. He reports that he has been coughing up a moderate amount of thick, green sputum for approximately one week that was accompanied by a fever of 100.6 and chills. NR 601 Week 8 Case Study Discussions Physical Examination

He took Ibuprofen 400 mg every 4 hours and increased his fluid intake for the last week. Two days ago he noticed that the sputum is now yellow rather than green and that he has not experienced any more fever. Overall, he feels like he is getting better. However, the dyspnea on exertion developed three days ago without relief despite the use of his Spiriva HandiHaler. He reports that he lost his rescue inhaler and has not had it to use in over 2 months. NR 601 Week 8 Case Study Discussions Physical Examination

PMH:

COPD

Hypertension

Osteoarthritis

Current medications:

Asprin-81 daily

Cyclobenzaprine 10 mg prn

Meloxicam 15 mg daily

Metoprolol 25 mg daily

Spiriva HandiHaler daily as directed

Tramadol 50 mg daily prn

Surgeries:

Appendectomy as a child (date unknown)

2004-Left cataract extraction with intraocular lens placement

2008-Right cataract extraction with intraocular lens placement

Allergies: NKA

Vaccination History:

Influenza vaccine- October 2013

Pneumovax-2010

His last TD-can’t remember

Has not a TDAP/TD in 20 years

Screening History:

Last Colonoscopy was 2012-normal

Last dilated retinal and glaucoma exam was 2013

Social history:

Retired roofer-stopped working in 2004 due to arthritis and pain in his rotator cuff. Is married and lives with spouse. They have 4 grown children who live within a 10 mile radius of them. Currently smokes-is down to ½ pack cigarettes daily. Has smoked for 45 years total. NR 601 Week 8 Case Study Discussions Physical Examination
Family history:

Father is deceased and had a history of hypertension and diabetes; Mother is deceased and had a history of CAD/MI; Sister-history of colon cancer.

Discussion Part One:

Provide differential diagnoses (DD)with rationale.

Further ROS questions needed to develop DD.

Based on the patient data provided, choose geriatric assessment tools that would be appropriate to use in conducting a thorough geriatric assessment. Provide a rationale on why you are choosing these particular tools. NR 601 Week 8 Case Study Discussions Physical Examination