Discussion Part Two (graded)
Physical examination:
Vital Signs: Height:
6’0 Weight: 140 pounds; BMI:
19.0 BP: 156/84 P: 84 regular R: 20
HEENT: normocephalic, symmetric PERRLA, EOMI; poor dentition
NECK: left neck supple; non-palpable lymph nodes; no carotid
bruits. Limited ROM
LUNGS: rhonchi in anterior chest bilaterally.
HEART: S1 and S2 audible; regular rate and rhythm
ABDOMEN: active bowel sounds all 4 quadrants; Normal
contour; RUQ tenderness; liver palpable
NEUROLOGIC: negative
GENITOURINARY: negative
MUSCULOSKELETAL: negative
PSYCH: PHQ-9 is 15
SKIN: oral mucosa irritated-stomatitis
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.
