Case Discussion: Physical Examination

Case Discussion: Physical Examination

Case Discussion: Physical Examination

Case Discussion: Physical Examination

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Discussion Part Two (graded) Physical Examination: Jo Age: 5- 8/12 year-old female Vital Signs: Height: 115 cm, Weight: 31 kg B/P:102/68, T: 97.9, HR: 90 BMP/reg., Resp: 18, reg, non-labored, SpO2: 99% Weight percentile: 99.1%, Height percentile: 64.0% HEENT: Head normocephalic atraumatic, hair thick and distributed throughout entire scalp; conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; pinna/tragus w/o tenderness; nares patent, unremarkable bil; pharynx unremarkable tonsils 2/4 bil; primary tooth eruption to include first molars upper and lower; no loose teeth; oral exam unremarkable; neck supple w/o lymphadenopathy; thyroid small, firm, equal bil. Vision remains unchanged from her first visit. Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored; abdomen sl. rounded normoactive bowel sounds throughout, soft, non-tender, no masses, or organomegaly; peripheral pulses reg., equal., intact bil radial and pedal. Musculoskeletal: MAE Cognitive or Behavioral: The patient was uncooperative this visit. The patient hides behind the exam table and tells her mother “no” frequently. She takes the exam paper off of the table, crawls around behind the exam table and kicks at her mother when the mother attempts to pull her out. You are able to get her out from under the table with much coaxing and a promise of a popsicle. There is difficulty to get her to stay focused while you examine her, and she asks frequent, tangential questions. She can copy a circle, square, and write her name but she has not yet learned to read or write letters beyond this. Discussion Questions Part Two Please add the following to your response: Primary diagnoses and differential diagnosis with rational and the following in brief for your primary diagnosis:

The routine physical, also known as general medical examinationperiodic health evaluationannual physicalcomprehensive medical examgeneral health checkpreventive health examinationmedical check-up, or simply medical, is a physical examination performed on an asymptomatic patient for medical screening purposes. These are normally performed by a pediatrician, family practicephysician, physician assistant, a certified nurse practitioner or other primary care provider. This routine physical exam usually includes the HEENT evaluation. Nursing professionals such as Registered Nurse, Licensed Practical Nurses can develop a baseline assessment to identify normal versus abnormal findings.[1] These are reported to the primary care provider. If necessary, the patient may be sent to a medical specialist for further, more detailed examinations.

The term is generally not meant to include visits for the purpose of newborn checks, Pap smears for cervical cancer, or regular visits for people with certain chronic medical disorders (for example, diabetes).[2] The general medical examination generally involves a medical history, a (brief or complete) physical examination and sometimes laboratory tests. Some more advanced tests include ultrasound and mammography.

If done for a group of people the routine physical is a form of screening, as the aim of the examination is to detect early signs of diseases to prevent them.[3]

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