NR602 Discussion Week 2 part 2

Discussion Part Two (graded)

Physical Examination of Lily:

V/S: Height- 160 cm, Weight- 45 kg, B/P 114/60, HR 90, RR 16, T 98.7, SpO2 99%

Awake, alert, oriented, cooperative. Difficulty with eye contact. Answers questions in short 1-2 word answers. HEENT: Head is normocephalic

PERRLA, EOMs intact, sclera clear, conjunctiva unremarkable. TM’s dull, grey, with cone of light reflex bil.

Nares patent, oral mucosa pink and moist. All teeth present except final set of molars upper and lower. Good dental hygiene.

Mucous membranes are moist and pink.

Neck: Neck supply without thyromegaly, normal ROM. No lymphadenopathy.

Pulmonary: Chest wall symmetric, respirations even and unlabored. Lungs CTA.

Cardiac: NL S1, S2. No murmurs or rubs. No JVD. No cyanosis, clubbing, or edema. 2+ pulses bilaterally at the carotid artery. 1+ pulses bilaterally at radial, DP, and PT arteries. No murmur or change in cardiac status with 1 min of vigorous activity in the office. Femoral and radial pulses equal bil from right to left and upper to lower.

Musculoskeletal: Able to do deep knee bends, heel-to-toe walking, stand on one leg for 10 seconds each, Adams forward bend negative.

Neurological: DTRs 2/5 throughout. MAE. Full active ROM.

Tanner: Breasts tanner III. Pubic hair Tanner IV

Discussion Questions Part Two

Based on the physical exam findings what are your primary, secondary, and differential diagnoses now?

Are further diagnostics needed, if so why? If not, why not?

Are any guidelines needed for this history and physical that were not used?

Should contraception be discussed this visit?

Does Lily need a pelvic exam?