NR601 Week 4.2
Discussion Part Two (graded)
Physical Exam:
Vital signs: blood pressure 128/84, heart rate 80
respirations 20, temperature 98.5
height 5’3”, weight 130 pounds
General: no acute distress
HEENT: Head normocephalic without evidence of masses or
trauma. PERRLA, EOMs intact. Noninjected. Fundoscopic exam unremarkable. Ear
canal without redness or irritation, TMs clear, pearly, bony landmarks visible.
No discharge, no pain noted. Neck negative for masses. No thyromegaly. No JVD
distention
Skin: intact
CV: S1 and S2 RRR, no murmurs, no rubs
Lungs: Clear to auscultation
Abdomen: Soft, nontender, nondistended, bowel sounds present
all 4 quadrants, no organomegaly, and no bruits
Musculoskeletal: No pain to palpation; Antalgic gait noted
when patient rises from seated position to standing and begins to walk. Active
and passive ROM decreased with stiffness
Neuro: Sensation intact to bilateral upper and lower
extremities; Bilateral UE/LE strength 5/5.
Discussion Questions Part Two
For the primary diagnosis explain how you would proceed with
your work-up and include the following: lab work and imaging studies
How would you manage this patient pharmacologically? Is it
appropriate that she is taking Ibuprofen prn?
What non-pharmacological strategies would be appropriate?
Describe patient education strategies.
Describe follow-up and any referrals that may be necessary.
