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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 5 Case Study Discussions Physical Examination (Part-1) NEW
Discussion Part One (graded)
C.W. is a tall, thin 78-year-old African American male brought into the office by his son who states that the patient is restless, angry, and has been unable to sleep for the last week. The son indicates that he is very concerned about his father because he lives alone. Also, he is concerned about the “strange” symptoms that his father has presented with recently.
Background:
C.W. presents as restless, hyperverbal, obnoxious and angry. He expresses himself by periodic yelling. He is unkempt and smells strongly of urine, alcohol and body odor. ………… has an unsteady gait and sways while standing. As you converse with the son, you determine that C.W. was medically separated from military service due to mental health issues after 2 years of active duty that ended in 1947. He has been married and divorced three times over the years. He typically seeks no acute or preventative medical care. ___ was treated by a psychiatrist previously, but he did not like taking the prescribed medications so he stopped taking them and did not keep any further psychiatric appointments.
PMH:
Patient denies any previous diagnoses. However, when asked why he saw a psychiatrist in the past, he tells you that the psychiatrist diagnosed paranoid schizophrenia, but that he does not have any psychiatric diagnoses or problems. He states: “It was just a way for him to make money off me coming in and seeing him and paying the drug companies for me to take all those meds!”
Current medications:
Denies prescription medications, over the counter medication, herbal therapies or vitamins.
Surgeries:
Denies surgeries
Allergies: NKA
Vaccination History:
Flu vaccine: never given
Pneumovax: never given
Tetanus: never given
Herpes zoster: never given
Screening History:
Last Colonoscopy was 2012-normal
Last dilated retinal and glaucoma exam was 2013
Social history and Risk Factors:
Patient admits to smoking cigarettes and cigars. …… estimates that he smokes about 1 pack of cigarettes daily for the last 40 years, and 2 cigars each week for the last 30 years.
He states that he drinks a 24 ounce bottle of beer 4-6 times a week. … denies drinking wine or hard liquor. …….. does admit to smoking marijuana on occasion but does not use other recreational drugs. Patient denies falling. You notice some scrapes on his forearms, and when asked, he tells you that he fell yesterday: “I got pretty drunk out fishin’ with friends and fell off my bike trying to ride home”. He does not use any assistive devices for ambulation or balance.
Significant ROS:
Productive cough with white sputum. Denies hemoptysis.
He answers “No” to the PHQ-2 screening questions.
Family history:
Reports no significant family history
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.
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