NR 601 Case Study Discussions Physical Examination Discussion

NR 601 Case Study Discussions Physical Examination Discussion

NR 601 Case Study Discussions Physical Examination Discussion

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

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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

 

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.