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Posted: June 15th, 2022
After completing the physical exam
Discussion Part Two (graded)VS: T 98.9, BP 116/78, P 100, R 22 Sao2 98%. Height 5â10â, Weight 200 pounds.General: Alert, oriented, and cooperative. HEENT: head normocephalic. Hair thick anddistribution throughout scalp. Sclera clear, conjunctiva whiteTympanic membranes gray and intact with light reflex noted. Pinna and tragusnontender. Nares patent without exudate. Oropharynx moist, no lesions, or exudate.Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck supple. Nolymphadenopathy. Thyroid midline, small and firm without palpable masses.Cardiopulmonary: Heart S1 and S2 noted, no murmurs, noted. Lungs clear toauscultation bilaterally. Respirations unlabored.Abdomen nontender, nondistended, with positive bowel sounds noted. Noorganomegaly noted.After completing the physical exam, you ask Ed about his social life. He states he goesout three to four nights a week with his friends to the bar for a few drinks. He is usuallyhome by 1 a.m.; this has been the norm since he started college. He says all his friendsdo the same thing, and they are doing fine. Further questioning about quantity revealsEd drinks five to six beers and usually one to two shots every time they go out. He hasan occasional drink the next morning, no one has ever told him he needs to stopdrinking, in fact he is the life of the party.CAGE questionnaire results:Have you ever felt you should cut down on your drinking? NoHave people annoyed you by criticizing your drinking? YesHave you ever felt bad or guilty about your drinking? NoHave you ever had a drink first thing in the morning to steady your nerves or to get rid ofa hangover (eye opener)? YesPHQ-9 Score- 10Discussion Questions Part Two:What is your primary diagnosis/diagnoses with ICD 10 code for Ed? Include therationale 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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