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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