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

Discussion Part Two (graded)

Physical examination:

Vital Signs:

Height: 5’8” Weight: 154 pounds BMI: 23.4 BP: 132/76 P: 76
regular R: 16

HEENT: Normocephalic, symmetric. PERRLA, EOMI, no cataracts noted; poor dentition.

NECK: Neck supple; non-palpable lymph nodes; no carotid bruits.
LUNGS: Respirations are unlabored, decreased breath sounds and crackles at the bases bilaterally. Prolonged expiratory phase throughout lung fields, inspiratory wheezes and a productive cough of cloudy white sputum.

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iscussion Part One (graded)

Ms. S. is a 62-year-old black female who has returned to the clinic to discuss her concerns that her lifestyle modifications to lose weight have not worked. At the last visit 3 months ago, she was advised to change her eating habits and increase activity to promote weight loss. She reports walking at least 30 minutes a day but has lost very little weight. ……….. indicates that the walking only made her extremely thirsty and hungry and attributes her increased thirst and hunger to increased exercise and her increased urination due to drinking more water since “it’s been hot lately” and exercise makes me thirsty”…… has returned to the clinic to discuss if there is anything else that can be done to lose weight and to determine why she is so tired, thirsty and hungry all the time. She also thinks she may have an overactive bladder since she has to urinate frequently during the day, which has influenced her not to go on outings with her friends.

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Discussion Questions Part One

Conduct a ROS on this patient.

Indicate which symptoms are most concerning to you.

List your differential diagnoses.

What types of screenings would be appropriate to use based on the chief complaint?

What primary diagnosis are you choosing at this point?

HEART: RRR with regular without S3, S4, murmurs or rubs.

ABDOMEN: Round, firm abdomen; active bowel sounds; non-tender.
NEUROLOGIC: Unsteady gait, swaying while standing during periods of agitation. Achilles reflexes are present bilaterally. Strength is equal but decreased in the upper and lower extremities bilaterally.

GENITOURINARY: Urinary incontinence with strong odor of urine. NO CVA tenderness.

MUSCULOSKELETAL: Mild kyphosis. Heberden’s nodes at the distal interphalangeal joints (DIP) of all fingers, and marked crepitus of the bilateral knees on flexion and extension. Pedal pulses palpable. No edema noted in lower extremities.

PSYCH: Manic, restless, angry and hyperverbal

SKIN: Right forearm with 3 cm x 5 cm x 0 cm dry, scabbed abrasion. Left forearm with 4 cm x 5 cm x 0 cm dry, scabbed abrasion.