Physical examination: Vital Signs Assignment

Physical examination: Vital Signs Assignment

Physical examination: Vital Signs Assignment

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Discussion Part Two (graded) Physical examination: Vital Signs: Height: 6’0 Weight: 140 pounds; BMI: 19.0 BP: 156/84 P: 84 regular R: 20 HEENT: normocephalic, symmetric PERRLA, EOMI; poor dentition NECK: left neck supple; non-palpable lymph nodes; no carotid bruits. Limited ROM LUNGS: rhonchi in anterior chest bilaterally. HEART: S1 and S2 audible; regular rate and rhythm ABDOMEN: active bowel sounds all 4 quadrants; Normal contour; RUQ tenderness; liver palpable NEUROLOGIC: negative GENITOURINARY: negative MUSCULOSKELETAL: negative PSYCH: PHQ-9 is 15 SKIN: oral mucosa irritated-stomatitis Discussion Part Two: Summarize the history and results of the physical exam. Discuss the differential diagnosis and rationale for choosing the primary diagnosis. Include one evidence-based journal article that supports your rationale and include a complete treatment plan that includes medications, possible referrals, patient education, ICD 10 Codes, and plan for follow up.

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© homeworkjoy.comThere are four primary vital signs: body temperature, blood pressure, pulse (heart rate), and breathing rate (respiratory rate), often notated as BT, BP, HR, and RR. However, depending on the clinical setting, the vital signs may include other measurements called the “fifth vital sign” or “sixth vital sign”

Vital signs (also known as vitals) are a group of the four to six most important medical signs that indicate the status of the body’s vital (life-sustaining) functions. These measurements are taken to help assess the general physical health of a person, give clues to possible diseases, and show progress toward recovery.[1][2] The normal ranges for a person’s vital signs vary with age, weight, gender, and overall health.[3]

There are four primary vital signs: body temperature, blood pressure, pulse (heart rate), and breathing rate (respiratory rate), often notated as BT, BP, HR, and RR. However, depending on the clinical setting, the vital signs may include other measurements called the “fifth vital sign” or “sixth vital sign”. Vital signs are recorded using the LOINC internationally accepted standard coding system.[4][5]

Early warning scores have been proposed that combine the individual values of vital signs into a single score. This was done in recognition that deteriorating vital signs often precede cardiac arrest and/or admission to the intensive care unit. Used appropriately, a rapid response team can assess and treat a deteriorating patient and prevent adverse outcomes