NR 601 Week 6 Case Study Discussions Physical Examination

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. NR 601 Week 6 Case Study Discussions Physical Examination

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. NR 601 Week 6 Case Study Discussions Physical Examination

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.

Description

ALL PARTS HAVE TO BE COMPLETED

Part 1 100-200 words

Primary Task Response: A patient may be referred to a medical specialty clinic for treatment. For that visit, an outpatient specialty note is prepared that follows the pattern for most medical notes and records. The record is referred to as a SOAP note, which stands for subjective, objective, assessment and plan (SOAP). NR 601 Week 6 Case Study Discussions Physical Examination

The clinician will review and document what the patient states is his/her problem or concern (subjective), perform an exam that might include laboratory tests and imaging studies and document the results (Objective), review and analyze the information (Assessment) as a diagnosis or list of possible diagnoses, and formulate a plan of action (Plan) such as treatment options or need for further testing. This becomes the record of that visit and a part of the patient’s electronic health record (EHR).

Click on the EHR Orthopedic Clinic Note link for this information and complete the assignment as follows: FIND LINK UNDER ATTACHEMENT NOTE

Read the EHR Orthopedic Clinic Note
Define the bolded terms and abbreviations in the EHR Orthopedic Clinic Note.
Summarize for the patient in your own words (laymen’s terms) what each section (subjective, objective, assessment and plan) of the Orthopedic Clinic note means.
What is the function of the musculoskeletal system? NR 601 Week 6 Case Study Discussions Physical Examination

Part 2 100-200 WORDS

Primary Task Response: When a patient is seen in the emergency department (ED) of a hospital, that visit is documented in an emergency department visit note. The ED note must be succinct, but complete. This is because the physician and patient encounter in the ED is the basis for continued care (admission or follow-up) by providers outside of the ED. It is also important for coding and billing that the information be accurate and complete in order to obtain proper reimbursement. This is true for all health records and documentation.

Click on the EHR Emergency Department Visit Note link for this information and complete the assignment as follows: FIND LINK UNDER ATTACHMENT NOTE 2

Read the Emergency Department Visit Note. NR 601 Week 6 Case Study Discussions Physical Examination
Define the bolded terms and abbreviations in the EHR Emergency Department Visit Note.
Summarize for the patient and his/her family in your own words (laymen’s terms) what each section (subjective, objective, assessment and plan) of the Emergency Department Visit Note means.
What are the major organs of the respiratory tract and what is the function of this body system?

Part 3 100-200 words

Primary Task Response: After surgery at the time of discharge, the patient may be scheduled for a post-operative clinic visit or a call by a surgical specialty nurse or physician assistant. A surgery follow-up note documents that visit or phone call. The practitioner in the surgeon’s office/clinic will document the patient’s history and exam results as well as the evaluation and plan for further treatment/management. NR 601 Week 6 Case Study Discussions Physical Examination

Click on the EHR Surgery Follow–Up Note link for this information and complete the assignment as follows: FIND LINK UNDER ATTACHMENT NAMED NOTE 3

Read the surgery follow-up note. NR 601 Week 6 Case Study Discussions Physical Examination
Define the bolded terms and abbreviations in the EHR Surgery Follow-Up Note.
Summarize for the patient in your own words (laymen’s terms) what each section (Subjective, Objective and Impression/Plan) of the Surgery Follow-Up Note means.
What is the function of the endocrine system in general? What is the function of the thyroid gland? Besides the thyroid gland, what are the other organs of this system? NR 601 Week 6 Case Study Discussions Physical Examination

Part 4 100-200 words

Primary Task Response: When a patient is discharged from a healthcare facility, a Discharge Summary is created to provide information and a plan of care to the patient as well as the care providers in the patient’s next setting of care. Discharge Summaries should include the reason why the patient was initially seen or admitted to the facility, what was found, the procedures or treatments that are administered to the patient, the patient’s condition on discharge, instructions for the patient and family, and the attending physician’s signature. NR 601 Week 6 Case Study Discussions Physical Examination

Click on the EHR Discharge Summary link for this information and complete the assignment as follows: FIND LINK UNDER ATTACHMENT NAMED NOTE 4

Read the Discharge Summary.
Define the bolded terms and abbreviations in the EHR Discharge Summary.
Summarize for the patient in your own words (laymen’s terms) what each section (subjective, objective, assessment and plan) of the Discharge Summary means.
What is the function of the urinary system and the major organs of this system? NR 601 Week 6 Case Study Discussions Physical Examination