Question 4 10 Points CASE 4 Subjective:The patient presents today after having a cabinet fall on her.(This describes how the injury occurred.) She states the people who put in the cabinet missed the stud by about two inches.The patient complains of cephalgia,(Patient complaint.) primarily occipital, extending up into the bilateral occipital and parietal regions.The patient denies any vision changes, any taste changes or any smell changes.The patient has marked amount of tenderness across the superior trapezius.(Patient complaint.) Objective:Her weight is 188 which is up 5 pounds from last time, blood pressure 144/82, pulse rate 70, respirations are 18.She has full strength in her upper extremities.DTRs in the biceps and triceps are adequate.Grip strength is adequate.Heart is a regular rate.Lungs are clear. Assessment:1. Cephalgia 2.Thoracic somatic dysfunction (Select codes for definitive diagnosis.) Plan:The plan at this time is to send her for physical therapy, three times a week times four weeks for cervical soft tissue muscle massage, as well as upper dorsal.We’ll recheck her in one month. What diagnosis code(s) are reported?
[Solved]: 10 Points CASE 4 Subjective:The patient presents…
Need help with your Vital Signs & Health Assessment case study or NCLEX preparation? Connect with a verified Nursing expert now.