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Physical examination:
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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.
