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	Herzing University Online (Acct #7485)	Xxxxxx is logged in.
	Case ID #: 1756-20180731-004 (Status: Approved)	Date of Service: 7/31/2018
		Student Information

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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