Discussion Part Two (graded)
Physical examination:
Vital Signs:
Height: 5’0” Weight: 150 pounds BMI: 29.3 BP: 120/64 T: 98.0 oral P: 68 regular R: 16, non-labored
HEENT: Normocephalic, symmetric. Evidence of prior cataract surgery
in both eyes. PERRLA, EOMI, cerumen impaction bilateral ears.
NECK: Neck supple; non-palpable lymph nodes; no carotid bruits.
LUNGS: Clear to auscultation
HEART: RRR with regular without S3, S4, murmurs or rubs.
ABDOMEN: Normal contour; active bowel sounds, LLQ tenderness.
PV: Pulses are 2+ BL in upper and lower extremities; no edema. No
evidence of peripheral neuropathy.
NEUROLOGIC: Negative
GENITOURINARY: No CVA tenderness
MUSCULOSKELETAL: Gait fluid and steady. No muscle atrophy or
asymmetry. Full ROM all joints. Strength 5/5 and equal bilaterally. Joint swelling in fingers both hands.
PSYCH: Flat affect; patient declined to answer PHQ-9 and GDS
SKIN: Grossly intact without rashes or ecchymosis.
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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