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(solution) After completing the physical exam


Discussion Part Two (graded) VS: T 98.9, BP 116/78, P 100, R 22 Sao2 98%. Height 5’10”, Weight 200 pounds. General: Alert, oriented, and cooperative. HEENT: head normocephalic. Hair thick and distribution throughout scalp. Sclera clear, conjunctiva white Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist, no lesions, or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. Cardiopulmonary: Heart S1 and S2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. Abdomen nontender, nondistended, with positive bowel sounds noted. No organomegaly noted. After completing the physical exam, you ask Ed about his social life. He states he goes out three to four nights a week with his friends to the bar for a few drinks. He is usually home by 1 a.m.; this has been the norm since he started college. He says all his friends do the same thing, and they are doing fine. Further questioning about quantity reveals Ed drinks five to six beers and usually one to two shots every time they go out. He has an occasional drink the next morning, no one has ever told him he needs to stop drinking, in fact he is the life of the party. CAGE questionnaire results: Have you ever felt you should cut down on your drinking? No Have people annoyed you by criticizing your drinking? Yes Have you ever felt bad or guilty about your drinking? No Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)? Yes PHQ-9 Score- 10 Discussion Questions Part Two: What is your primary diagnosis/diagnoses with ICD 10 code for Ed? Include the rationale and a reference for your diagnosis. What is your first line treatment plan for Ed including medications, labs, education, referrals, and follow-up?

 


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