Discussion Part Two (graded) Physical examination Vital Signs: Height: 5 feet 7 inches Weight: 170 pounds Waist Circumference “� 32 inches BP 130/84 T 98.0 po P 92 regular R 22, non-labored HEENT: normocephalic, symmetric. Evidence of prior cataract surgery in both eyes. PERRLA, EOMI, cerumen impaction bilateral ears. Several broken teeth, loose partial plate. NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. LUNGS: Decreased breath sounds bases bilaterally, clear to auscultation HEART: RRR with regular without S3, S4, murmurs or rubs. ABDOMEN: Bloated appearance, active bowel sounds, LLQ tenderness and 6 cm x 7 cm mass. PV: Pulses are 2+ BL in upper and lower extremities; no edema 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. Hips: Discomfort on flexion in both hips; extensor and flexor strength symmetrical. Knees: Left knee discomfort with weight bearing. No redness, warmth or edema. Full ROM in both knees with symmetrical extensor and flexor strength. Crepitus on extension of left knee. Hands: No redness or swelling. Bilateral joint tenderness of the distal interphalangeal and proximal interphalangeal joints of the 2nd and 3rd digits. Calf circumference-31 cm; Mid-arm circumference- 22 cm PSYCH: normal affect SKIN: Pale. Areas of healing ecchymosis: Left knee- 3 cm x 2 cm x 0 cm. Right knee -2 cm x 2.5 cm x 0 cm. 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.
Previous answers to this question
This is a preview of an assignment submitted on our website by a student. If you need help with this question or any assignment help, click on the order button below and get started. We guarantee authentic, quality, 100% plagiarism free work or your money back.
Get The Answer