Discussions Physical Examination

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.

You meet your first patient of the morning. A.K. is a 65-year-old Caucasian male who you are seeing for the first time. Both wife and daughter are present.

Background

He reports that he has had an 18-pound unintentional weight loss in the last 2 months “I am just not hungry anymore, and when I do eat, I get full so fast. In fact, it is really hard to eat, and I don’t eat nearly as much as usual, even though I eat 3 times every day”. He also reports feeling more tired than usual. “I am not sleeping very well. My wife wakes me up when I am snoring, or when she thinks I am not breathing. I used to have sleep apnea, but I don’t think I have it anymore. Besides, that mask is so horrible to wear.” He reports day time somnolence. He reports that he is at the clinic today because of his wife and daughter’s concern about his weight loss and loss of appetite.

PMH

Mr. A.K. has a history of hypertension, cataracts, and osteoarthritis.
Current medications:

Ibuprofen 600 mg po TID

Lisinopril 20 mg po QD

Hydrochlorothiazide 25 mg PO QD

Simvastatin 20 mg po QD

Vitamin D3 50,000 units po weekly

Omeprazole 40 mg po QD

Sudafed 50 mg po TID prn

Surgeries

April 2010-Right cataract extraction with Intraocular Lens Placement
June 2010- Left cataract extraction with Intraocular Lens Placement
November 2011-Left total knee arthroplasty

Allergies: No known drug or food allergies. Allergies to latex causing difficulty breathing and to bee stings, causing widespread edema and airway obstruction.

Vaccination History

He receives annual flu shots “most of the time”. His last one was 18 months ago.

Received a Pneumovax “the day I turned 65”.

His last TD was greater than 10 years ago.

Has not had the herpes zoster vaccine.

Social history

He has an 8th grade education and is a retired concrete finisher. He lives with his wife of 45 years and his daughter lives next door. He enjoys working in his back yard garden and recently tripped over the garden hose last week where his neighbor had to come and help him up.

Family history

Both parents are deceased. Father died of a heart attack at the age of 80; mother died of breast cancer at the age of 76. He has one daughter who is 45 years old and has hypertension. Hypertension, coronary artery disease, and cancer runs in the family.

Habits

He drinks one 4 ounce glass of red wine nightly; previous smoker of 30 years; he quit for 10 years, and is now smoking ¼ pack per day for the last 6 months.

Discussion Part One:

Provide the differential diagnoses (DD) with rationale