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.Evidence of prior cataract surgery in both eyes. PERRLA, EOMI, cerumen impaction bilateral ears.
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. I have the primary diagnosis as colon cancer.
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