Physical Exam:

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.

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