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Discussion Part Two (graded)
Physical examination:
Vital Signs:
Height: 5’8” Weight: 188 pounds BMI: 28.58 BP: 130/70 T: 99.0 oral P: 72 regular R: 24, pursed-lip breathing; Pain level-7-right shoulder HEENT: Normocephalic, symmetric. PERRLA, EOMI, cerumen impaction bilateral ears.
NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. LUNGS: Labored respirations; posterior RLL, LLL, RML, LML diminished breath sounds. Rhonchi right and left anterior chest.
HEART: RRR with regular without S3, S4, murmurs or rubs. ABDOMEN: Normal contour; active bowel sounds, LLQ tenderness.
PV: Diminished pedal pulses; hair loss noted over extremities.
NEUROLOGIC: Negative
GENITOURINARY: Urinary dribbling, urgency, gets up 4 times during the night, distended bladder.
MUSCULOSKELETAL: Limited ROM in right shoulder. Crepitus in knees bilaterally.
PSYCH: Negative
SKIN: Negative
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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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.
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.
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