36353 -10 - Pages within 24hrs
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NPST Student Tracking System - Data Entry Section |
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CASE LOG DETAILS |
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Herzing University Online (Acct #7485) |
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Case ID #: 1756-20180731-004 (Status: Approved) |
Date of Service: 7/31/2018 |
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Student Information |
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Semester: Spring
Course: NU 609 Advanced Health Assessment
Preceptor: FLORES, MAY DR
Clinical Site: FLORES AND FLORES ASSOCIATES
Setting Type: Rural visit -
Patient Demographics
Age: 73 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: Other
Clinical Information
Time with Patient: 15 minutes
Consult with Preceptor:
Type of Decision-Making: Moderate complexity
Student Participation: Shared (50-50)
Reason for Visit: Follow-up (Consult)
Chief Complaint: Follow up Exam.Had Blood Work done.
Encounter #: No response
Type of HP: Problem Focused
Social Problems Addressed: Safety
Prevention
Education/Language
Nutrition/Exercise
Procedures/Skills (Observed/Assisted/Performed)
General Skills - Calculate BMI (Perf)
General Skills - Ear exam (Perf)
General Skills - Measurement of height (Perf)
General Skills - Visual exam (Perf)
General Skills - Weight (Perf)
ICD-10 Diagnosis Codes
#1 - K21.9 - GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS
#2 - Z72.0 - TOBACCO USE
#3 - 110 is not a valid ICD code.
#4 - E11.40 - TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSP
#5 - E78.2 - MIXED HYPERLIPIDEMIA
#6 - M 54.5 is not a valid ICD code.
#7 - D50.9 - IRON DEFICIENCY ANEMIA, UNSPECIFIED
#8 - N39.42 - INCONTINENCE WITHOUT SENSORY AWARENESS
CPT Billing Codes
Medications
OTC Drugs taken regularly: 3
Prescriptions currently prescribed: 0
New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit: Adherence Issues with Medications:
Other Questions About This Case
Age Range: 85 years and older
Clinical Setting: Primary Care
Patient Type:
History of Patient Illness (HPI): type 2 Dm,GERD,HTN
Patient Education: Smoking, Quitting
Patients Primary Language: English
Time spent performing family assessment: 15 minutes
Other:
Alcohol use or abuse disorder:
Breast exam:
Cervical exam:
Diabetic consultation:
Did you chart on patient record?: Yes
Discussed management with preceptor:
Domestic violence assessed:
History of tobacco use: Yes
Handled visit independently: Yes
Preceptor present during visit: Yes
Lab review: Yes
Newborn assessment:
Early postpartum visit <1 week:
Mental health referral:
Contraception visit:
Clinical Notes
Subjective
CC: Patient present for follow up exam..
HPI: Patient is a 73 year old here for a 4 month follow up exam. Patient had his bloodwork done and UA C & S which showed 1000cfu/ml ( not enough treat) He said that the had his bladder and renal scan done here.
PMH:
Problem List: Type 2 Diabetes Mellitus, Essential Hypertension, Gastroesophageal reflux disease, Essential Hypertension
Health Maintenance:
EKG
Declined Flu Shot, Pneumonia, shingles vaccine- this as of 10/6/2015 Living Will- 2012 pg 9 of Archived Records. Medical Problems :
Non Insulin Dependent Diabetes, Neuropathy, Diabetic, Hypertension, Gastroesophageal Reflux Disease Surgical Hx:
No Past History of Procedure
Hospitalizations:
None
Reviewed, No changes.
ROS :
Const: Denies constitutional symptoms
Eyes: Denies eye symptoms
ENMT :Denies ear symptoms. Denies nasal and sinus symptoms. Denies mouth or throat symptoms
CV : Denies cardiovascular symptoms
Resp : Denies respiratory symptoms
GI : Denies gastrointestinal symptoms
GU : Denies urinary symptoms
Musculo: Denies musculoskeletal symptoms
Skin: Denies skin, hair and nail symptoms
Neuro : Denies neurologic symptoms
Psych : Denies psychological symptoms
Endocrine: Denies endocrine symptoms
Hema/Lymph: Denies hematologic symptoms
Allergy/ Immuno: Denies allergic/immunologic symptoms
Meds Prior to Visit:
Lisinopril 20 mg 1 every day
Omeprazole 20 mg take one capsule by mouth daily
Welchol 625 mg one pill three times a day
BP Pen Needle Short 31 GX5/16 " use as directed.
Aspirin Ec 81 mg 1 po qd
BP pen Needle/ Short/Ultrafine/ 31GX5/16" 31G X 8mm use as directed
Metformin HCL 1000 mg take 1 tablet by mouth twice a day
Tamsulosin HCL 0.4 mg 1 by mouth every day
Keflex 500 mg 1 by mouth twice a day
Gabapentin 600 mg 1 three times a day.
Lidocaine HCL 4% apply to affected area tid
Januvia 100 mg 1 by mouth every day
Enalapril Maleate 10 mg take 1 tablet daily
Levemir Flex touch 100 Unit/ML inject 33 units every day
Tamsulosin HCL 0.4 mg take by mouth once a day.
Allergies : Baclofen
FH:
Cancer-Brother- (deceased)
Reviewed No changes
SH:
Marital: Legal Status: Married. Lives With: Spouse. Occupation: Retired Personal Habits: Smoking: Patient is a current smoker, smokes
every day- Patient was advised the risk of smoking such as cancer, COPD and premature death. Alcohol : Denies alcohol use Drug Abuse:
Never used drugs. Daily Caffeine: Consumes on average 1 cup of regular coffee per day, Consumes on average of 48 oz of soda per day.
Sexual Hx :
Contraceptive: Current methods include abstinence
Reviewed, No changes
Date : 07/ 31/2018
Was the patient queried about smoking behavior? Yes
Does the patient current smoke? Smoking: Patient is a current smoker, smokes every day- Patient was advised of the risk of smoking such as cancer, COPD and premature death.
Was the patient counseled about smoking cessation? Yes.
Objective:
Ht: 70.25" 5'10.25" Wt: 159 lb oz. Wt Prior 65 lb 2 oz as of 06/18/18 Wt.Dif: -6lb-2 Ooz. BMI : 22.6 BSA : 1.90 BP:144/82 Resp: 18 Pulse: 96
T:97.5 Pain Level: 8 O2SatR:99
Exam:
Const: Appears well developed and well nourished. No signs of acute distress present.
Head/Face: Normal to inspection
Eyes : EOMI both eyes. Conjunctivae clear. PERRL
ENMT : External ears WNL. External canals are clear and dry. Tympanic membranes are intact. Nasal mucosa is clear. Oropharynx: Appears normal. Posterior pharynx is normal
Neck: Palpation reveals suppleness. Thyroid is normal to palpation.
Resp : Respiration rate is normal. Chest expansion is symmetrical. Lungs are clear bilaterally.
CV : Rate is regular. Rhythm is regular.S1 is normal.S2 is normal. No heart murmur appreciated. Pedal pulses palpable
Abdomen : Positive bowel sounds. Abdomen is soft, nontender, and nondistended.
Musculo : Walks with normal age for gait. Upper Extremities: Normal to inspection. Lower Extremities : Normal to inspection
Skin : Skin is warm and dry.
Assessment # 1: k21.9 Gastro esophageal reflux disease without esophagitis
Care Plan :
Comments. : Patient sign his Living Will
Reviewed Medication
Reviewed Poly Pharmacy
Assessment # 2 : Z72.0 Tobacco Use
Care Plan :
Comments : Smokes half a pack a day
Declines Pneumonia Shot
Declines Bone Density Scan
He will think about Abnormal Aortic Aneurysm Screening next
next OV.
Advised patient to quit smoking.
Discussed with patient the risk of tobacco use including lung and
Cardiovascular disease, as well as negative outcomes including
stroke, heart attack and cancer, respiratory failure, oxygen
dependence. Encouraged cessation and offered assistance.
Pat. Edu : Smoking, Quitting
Assessment # 3 :110 Essential Hypertension
Care Plan :
Comments : Current BP 144/82
Pt reports BP range 140-80-90
Recheck BP 130/80
Advised to bring BP machine for comparison
Advised to start low salt diet.
Continue current med regimen
Assessment # 4 : E11.40 Type 2 Diabetes Mellitus with diabetic neuropathy, Unspecified
Care Plan :
Comments : Pt reports no s/ s hypo/hyperglycemia
Discussed s/s hypoglycemia
BS range: 940-110
Assessment # 5 : E78.2 Mixed Hyperlipidemia
Care Plan :
Comments :Patient was advised low cholesterol, low triglyceride diet.
Assessment # 6 : M54.5 Low Back Pain
Care Plan :
Assessment # 7 : D50.9 Iron deficiency anemia, unspecified
Care Plan :
Comments : Discussed lab results
Results reflect Iron deficiency anemia
Patient denies N/V/ D/, denies blood in stool/sputum.
Recommended colonoscopy-SWGI consult
Repeat labs x2 weeks to r/o acute, active bleeding
Lab Orders : CBC
Comp Metabolic Panel
Occult Blood # 3 Stool
Order : Colonoscopy
Follow Up : 2 weeks
Referral to SWGI for Anemia
Referral to Dr. Ryan, urology for incontinence
Assessment # 8 : N39.42 Incontinence without sensory awareness
Care Plan :
Comments : Pt states Inability to hold urine
Pt referred to Urology- Dr. Ryan
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