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Posted: June 15th, 2022
After completing the physical exam
Dialogue Half Two (graded)VS: T 98.9, BP 116/78, P 100, R 22 Sao2 98%. Top 5â10â, Weight 200 kilos.Basic: Alert, oriented, and cooperative. HEENT: head normocephalic. Hair thick anddistribution all through scalp. Sclera clear, conjunctiva whiteTympanic membranes grey and intact with gentle reflex famous. Pinna and tragusnontender. Nares patent with out exudate. Oropharynx moist, no lesions, or exudate.Tonsils ¼ bilaterally. Enamel in good restore, no cavities famous. Neck supple. Nolymphadenopathy. Thyroid midline, small and agency with out palpable lots.Cardiopulmonary: Coronary heart S1 and S2 famous, no murmurs, famous. Lungs clear toauscultation bilaterally. Respirations unlabored.Stomach nontender, nondistended, with constructive bowel sounds famous. Noorganomegaly famous.After completing the physical exam, you ask Ed about his social life. He states he goesout three to 4 nights per week along with his mates to the bar for just a few drinks. He’s usuallyhome by 1 a.m.; this has been the norm since he began school. He says all his friendsdo the similar factor, and they’re doing high-quality. Additional questioning about amount revealsEd drinks 5 to 6 beers and often one to 2 photographs each time they exit. He hasan occasional drink the subsequent morning, nobody has ever instructed him he must stopdrinking, the truth is he’s the lifetime of the get together.CAGE questionnaire outcomes:Have you ever ever felt you must reduce down in your ingesting? NoHave folks irritated you by criticizing your ingesting? YesHave you ever felt unhealthy or responsible about your ingesting? NoHave you ever had a drink very first thing in the morning to regular your nerves or to get rid ofa hangover (eye opener)? YesPHQ-9 Rating- 10Dialogue Questions Half Two:What’s your major analysis/diagnoses with ICD 10 code for Ed? Embrace therationale and a reference on your analysis.What’s your first line therapy plan for Ed together with drugs, labs,schooling, referrals, and follow-up?
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