strength, 5-full range of motion against gravity, with resis-tanceHypoglossal XII:Tongue symmetric with no abnormalitiesExpected deep tendon reflexes to bilateral triceps, bilateral biceps, bilateral brachioradialis, bilateral patellar, and bilat-eral Achilles tendonPoint-to-point movements smooth and accurate bilaterallyTina was able to perform coordination with rapid alternating hand movements without difficulty Her gait observed to be steady with continuous, symmetric stepsGraphesthesia indentified bilaterally Expected sensation in proximal and distal bilateral arms andlegs to dull, soft, and sharp touch.Position sense intact in fingers and toesStereognosis intact bilaterally CardiovascularUnable to assessClick or tap here to enter text.Click or tap here to enter text.
MusculoskeletalUnable to assess Click or tap here to enter text.Click or tap here to enter text.GastrointestinalUnable to assessClick or tap here to enter text.Click or tap here to enter text.GenitourinaryUnable to assessClick or tap here to enter text.Click or tap here to enter text.PsychiatricUnable to assessClick or tap here to enter text.Click or tap here to enter text.GynecologicalUnable to assessClick or tap here to enter text.Click or tap here to enter text.Problem List1.Headache6 Hypertension11 Activity intolerance2 Diabetes Mellitus type 27 Stress12 Click or tap here to enter text.3 Asthma 8 Dysmenorrhea13 Click or tap here to enter text.4 Neck pain9 Menorrhagia14 Click or tap here to enter text.5 Obesity10 Polycystic Ovarian Syndrome15 Click or tap here to enter text.
DiagnosisICD-10 CodePertinent FindingsTraumatic Headache (Acute post)G44.31 Chief complain of headaches, pain is on the crown of the head and back of the head. It started a couples of days after the low speed accident lasting from 1 to 2 hours daily. Strain of muscle, fascia and ten-don at the neck levelS16.1Chief complain is pain that is located on the back of the neck muscles when moving the head and neck Type 2 Diabetis Mellitus with un-specified diabetic retinopathyE 11.31Cotton wool spots noted on the right fundus upon examination with opthalmoscope Diagnostics: List tests you will order this visitTestRationale/Citationn/aClick or tap here to enter text.n/aClick or tap here to enter text.P:PlanAddress all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention. A: AssessmentMedical Diagnoses. Provide 3 differential diagnoses which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis.
Click or tap here to enter text.Click or tap here to enter text.
You've reached the end of your free preview.
Want to read all 17 pages?
- Fall '15