Summarize the history and results of the physical exam.

Physical examination:

Vital Signs:

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Height: 5’0” Weight: 150 pounds BMI: 29.3 BP: 120/64 T: 98.0 oral P: 68 regular R: 16, non-labored

HEENT: Normocephalic, symmetric. Evidence of prior cataract surgery in both eyes. PERRLA, EOMI, cerumen impaction bilateral ears.

NECK: Neck supple; non-palpable lymph nodes; no carotid bruits.

LUNGS: Clear to auscultation

HEART: RRR with regular without S3, S4, murmurs or rubs.

ABDOMEN: Normal contour; active bowel sounds, LLQ tenderness.

PV: Pulses are 2+ BL in upper and lower extremities; no edema. No evidence of peripheral neuropathy.

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. Joint swelling in fingers both hands.

PSYCH: Flat affect; patient declined to answer PHQ-9 and GDS

SKIN: Grossly intact without rashes or ecchymosis.

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.