Nursing Homework week 5, Clinical

· Semester: Fall

· Course: MSN5700C Advanced Practice in Primary Care I

· Preceptor: Rural Visit: No

· Underserved Area/Population: Yes

Patient Demographics

· Age: 42 years

· Sex: Female

· Race: Hispanic

· Insurance: PPO

· Referral: No referral

Reason for Visit: Follow-up Type of Decision-Making: Moderate Chief Complaint: “I’m here for follow-up of my anemia and fibroids; they are planning surgery.” Type of H & P: Follow-up visit

History of Present Illness (HPI): A 42-year-old Hispanic female presents for follow-up of chronic anemia related to abnormal uterine bleeding secondary to uterine fibroma. She reports history of heavy, prolonged menstrual periods for over a year, associated with fatigue and weakness. She was previously diagnosed with uterine fibroids and is scheduled for hysterectomy once her hematologic status is optimized. She continues oral iron supplementation. Denies chest pain, palpitations, or shortness of breath at rest.

Past Medical History:

· Chronic iron-deficiency anemia

· Uterine fibroma

Medications:

· Ferrous sulfate 325 mg PO daily

· Multivitamin

Physical Exam (Pertinent):

· General: Alert, oriented, in no acute distress.

· Vitals: Stable.

· Cardiovascular: Regular rate and rhythm, no murmurs.

· Respiratory: Lungs clear bilaterally.

· Abdomen: Soft, non-tender, no masses palpated.

· Extremities: No edema.

Assessment/Plan:

1. Chronic Iron-Deficiency Anemia (D50.9): Continue iron supplementation, reinforce adherence, recheck CBC in 4 weeks.

2. Uterine Leiomyoma (D25.9): Candidate for hysterectomy; optimize preoperative status with hematology clearance.

3. Menorrhagia with Regular Cycle (N92.0): Symptom management until surgical intervention.

Plan: Continue oral iron, encourage iron-rich diet, follow-up labs (CBC, iron studies). Surgery planning coordinated with gynecology. Educated patient about importance of compliance with treatment to improve hemoglobin before procedure.

Social Problems Addressed:

· Growth & Development (reproductive health)

· Income/Economic (impact on work due to fatigue, planning for surgery)

Clinical Notes (Typhon text box): Female patient with chronic anemia secondary to heavy menstrual bleeding caused by uterine fibroids. Currently managed with iron supplementation and scheduled for hysterectomy once hemoglobin is optimized. Patient reports improved energy with therapy, denies chest pain or SOB. Plan includes continued oral iron, dietary counseling, and repeat labs. Coordination with gynecology for surgical clearance.

ICD-10 Diagnosis Codes:

· D50.9 – Iron deficiency anemia, unspecified

· D25.9 – Leiomyoma of uterus, unspecified

· N92.0 – Excessive and frequent menstruation with regular cycle

CPT Codes (Billing/Labs):

· 85027 – CBC, automated

· 83540 – Iron studies

· 36415 – Venipuncture, routine