NU611 2020 September Unit 2 Discussion Latest

NU611 Clinical Decision Making

Unit 2 Discussion

New Patient Encounter

Instructions:

Review the SOAP note accessed through the link below.  For purposes of the assignment the patient is an ‘new patient’ in the practice.

New Patient SOAP NotePreview the document

Initial Post

Use your lecture materials to determine what CPT E&M Code to utilize for this ‘new patient’ encounter.

Provide justification for the code you assigned by including the following information in your discussion:

the level of history taking achieved – identify the history elements present

the type of exam performed – identify the number of systems and bulleted points in the note

the level of medical complexity encompassed – include # of points for a) diagnoses/management options, b) amount/complexity of data reviewed and c) level of risk for complications, morbidity, mortality

Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.

The post and responses are valued at 20 points. Please review post and response expectations. Please review the rubric to ensure that your response meets criteria.

Estimated time to complete: 2 hours

Peer Response: Unit 2, Due Sunday by 11:59 pm CT

New Patient Encounter

Instructions:

Consider the knowledge you have gained from this week’s lecture.

Construct a response to at least 2 of your peers commenting – ideally one who assigned the same CPT E&M Code that you did and one that did not.

Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.

*Subjective

CC: chief complaint – "I have a rash that will not go away, and it is spreading."

HPI: history of present illness –40 year old male presents today with a rash that he first noticed two months ago. He states the rash started on his chest, but over the last three weeks it has spread to his back and both arms. The patient says that the rash is dry, but not itchy. He denies any pain associated with the rash. The patient states that there is nothing that aggravates the rash. The patient has tried over the counter creams and lotions with no relive. The patient is concerned that the rash has been there for two months and is beginning to get worse.

PMH: past medical history –

Hypoglycemia - 2010

Allergies: NKDA

Medications:

Ketoconazole 2% External Shampoo. Apply to dampened skin, lather, and leave on for five min then rinse. Apply single-use daily for three days.

Social history:

Married

Current every day smoker

Alcohol: 6 pack beer daily

Recreational or chemical drug use: Denies

Exercise: None

Seatbelt use 50% of the time

Sun Exposure frequent

Family history:

Father Deceased, Cardiac issues

Mother Deceased, Cardiac issues, MI

Paternal grandmother HTN, Cardiac 78

Paternal grandfather Deceased Stroke 58

Maternal grandmother Diabetic type 2 age 75

Health Maintenance/Promotion:

Wellness Adult Exam/DOT physical (2018)

Flu (2018)

TD (2015)

Exercise none

Seatbelt 50% of the time

Review of Systems (ROS):

General: Denies, fatigue, fever, and night sweats. Denies anorexia, malaise, weight loss, weight gain, and sleep disorder

Skin: Complains of a dry rash to back, chest, and both arms that seem to be spreading.

HEENT: Denies blurred vision, double vision, halo, light sensitivity, eye irritation eye discharge, and eye pain. Denies ringing in the ears, ear discharge, earache, nosebleeds, difficulties swallowing. Denies hoarseness and sore throat Neck: Denies decreased ROM, pain with movement or difficulty swallowing

CV: Denies chest pain or discomfort, racing/skipping heartbeats or palpitations, lightheadedness, near fainting, fainting, shortness of breath with exertion, difficulty breathing while lying down and leg cramps with exertion

Lungs: Denies shortness of breath at rest, shortness of breath with activity, sleep problems related to breathing, wheezing, excessive sputum, coughing up blood and excessive snoring

GI: Denies indigestion, loss of appetite, nausea, vomiting, abdominal pain, bloating, gas, change in BM's, diarrhea, constipation, blood with BM's Hemorrhoids, and dark-tarry stools.

GU: Denies frequency, pain with urination, blood in urine, urinary incontinence or leaking, difficulty starting the urinary stream, difficulty emptying the bladder, and nighttime urination.

PV: Denies swelling, leg cramps, and coldness

MSK: Denies weakness, swelling, joint pain or stiffness, back pain, neck pain, muscle cramps, muscle stiffness, and gout

Neuro: Denies numbness and tingling, seizures, stroke, headache, tremors, memory loss or dizziness

Endo: Denies heat or cold intolerance, excessive thirst or excessive hunger

Psych: Denies trouble concentrating, nervousness, anxiety, panic attacks, mood changes, hearing voices, feeling unhappy, desire to harm self/others, sleep troubles, nightmares, memory loss, and stress

*Objective:

Physical Examination

VS:

Weight 197

Height 74.5 in

BMI 25.05

BP 130/86

Temp 98.9

PR 70

RR 18

Gen: On physical exam, the patient is alert and oriented in no acute distress.

Skin and hair: Hyperpigmented fine scaly macules that cover bilateral arms, anterior and posterior trunk. Edges are well defined, but the macules overlap.

HEENT:

Head: Symmetrically round, no lesions or bumps noted Face is oval and symmetrical

Eyes: No redness, discharge, or crusting noted to eyelids, Conjunctiva, and sclera are moist and smooth.

The sclera is white with no lesions or redness. Eyes are symmetrical.

Ears: Equal in size bilaterally. Skin is smooth, no lumps, lesions, or nodules noted. No drainage noted non-tender on palpations.

Nose: No deformity, discharge, inflammation, or lesions

Throat/Mouth: No deformity or lesions with good dentitions. Lips are moist and pink. The tongue is midline, moist and pink with normal movement

Neck: The neck is symmetrical with a centered head position and no bulging masses. The thyroid gland is nonvisible. The trachea is midline. No difficulty swallowing.

CV: Regular rate and rhythm. Apical pulse 70. No JVD noted

Lungs: Respirations 18/minute, relaxed, and even. Chest expansion symmetric. No pain or tenderness on palpation. Lung sounds are clear in all lung fields.

Abd: The umbilicus is midline with no bulging noted. The abdomen is flat and symmetric. No pain or tenderness on palpation. No guarding. Bowel tones are active in all four quadrants.

GU: No complaints patient reports voiding without difficulties

PV: No edema noted. No clubbing of fingers or toes. Capillary refill is less than 3 seconds. Skin is warm.

Pulses strong and equal. No visible varicosities noted.

MSK: Full ROM in both arms and legs. No weakness noted. Gait is smooth and steady. Extremities are symmetrical

Neuro: PERRLA, no tremors noted. The patient is alert and oriented

Psych: Alert and cooperative, normal mood and effect, normal attention span and orientation, memories intact

*Assessment:

Diagnosis

1. Tinea Versicolor B36.0

2. Alcohol abuse F10.10

*Plan:

1. Diagnostics: KOH prep obtained and shows fungal spores.

Therapeutic: Ketoconazole 2% external shampoo apply to dampened affected skin, lathered left on for 5 min then rinse. Apply single-use daily for three days. Dispense one bottle with one refill.

Educational: The patient was educated on the importance of using shampoo as prescribed. The patient was educated to decrease or stop drinking alcohol. The patient was instructed to follow up if the symptoms do not improve or if it gets worse.

Consultation/Collaboration: N/A

2. Diagnostics: N/A

Therapeutic: N/A

Educational: The patient was educated on the dangers of drinking while taking medication. The patient was educated on the possible affects on his liver. The patient was counseled to stop drinking or decrease amount.

Consultation/Collaboration: Quality Behavior Health