Week 3: Discussion Part One
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Setting: large urban city family practice clinic which employs physicians and nurse practitioners.
It is Monday here at your clinic. In addition to your regularly scheduled you are being asked to add some additional patients. You note your next visit is a work-in for cough. You review the chart before entering the room to familiarize yourself with this patient’s chart. Katie has been coming to the clinic for years and she and her husband are well known to you but you still review the chart prior to entering the room to assure you are familiar with her history and previous visits. Most of her visits have been for yearly wellness checkups and her labs and vitals are great, even at age 65.
When you enter the room you see a well-dressed woman looking her stated age sitting on the exam table. Also present is a man who appears to be about 40, the woman introduces him as her son Patrick. Patrick has brought his mother in-law to the clinic today because he is concerned about her cough, it is not getting better. Katie says her son-in-law is worried for nothing but she has had the cough for a bit and it does not seem to be getting better at all.
Katie describes herself as normally really healthy. This cough started a week ago and it is worse at night. The cough wakes her up. Her chest is starting to hurt from all the coughing. She has noticed that she has been more tired and gets easily winded when she takes her daily walks. She has not gone to Curves this week like she usually does because she doesn’t have the energy. She doesn’t think she has fever, did not take her temperature.
Had chicken pox, measles and rubella as a child. Katie has a history of osteopenia, HTN and hyperlipidemia. Takes a daily multivitamin, Evista 60 mg daily and HCTZ 25 mg daily. No reports of past injuries. Previous surgeries include a tonsillectomy and cholecystectomy. Hospitalized for surgeries and childbirth. Has seasonal allergies to pollen and reports hayfever. She is allergic to Demerol, it makes her vomit. No alcohol or tobacco use.
Married to John, they live with their married daughter and her family. Takes care of the kids and home as Mary and her husband work. Her husband and son-in-law both smoke, but not in the house.
Discussion Part One:
What further questions do you have for Katie at this visit??
Use OLDCARTS to guide your questions. Link the questions to your differential diagnoses.
What is your differential diagnosis list with ICD 10 for this visit thus far? Each differential diagnosis should include a one sentence pathophysiology statement supported by the literatureor the textbook.Include the patient’s signs and symptoms and include a rationale statement that explains how the diagnosis is appropriate for your patient.
Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests would you order?
Week 3: Discussion Part Two
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Interview information: Upon further questioning about sore muscles, she points to area on right side where she is sore from coughing. It hurts in that spot every time she tries to take a deep breath. No reports of headache, fever, or vision changes. No reports of nasal congestion, or discharge. States she has not been hoarse. No report of wheezing or shortness of breath with rest. No reports of palpitation, dizziness or enlarged lymph nodes. No reports of heartburn, or indigestion. Tried some cough syrup but that does not stop the cough for long, nothing seems to make it better.
VS: Height: 62 inches weight: 140 pounds. T: 100.4, BP 130/90, P 80, R 22, even, oxygen saturation: 96%
Cooperative, talkative, appropriate. Skin color is pale pink, no cyanosis or pallor. HEENT: Head normocephalic, Hair thick and distributed throughout entire scalp. Conjunctiva clear, non-icteric, PERRLA, EOM’s intact. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender. Nares patent without exudate. Oropharynx moist, no lesions or exudate. Teeth in good repair, no cavities noted. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small, firm. CARDIOPULMONARY: Heart RRR w/o murmur. Respiratory: Lung sounds are clear left side. Right side: crackles noted on inspiration, did not clear with coughing. On assessment of expansion a slight lag was noted on right side. Tactile fremitus symmetrical. An asymmetrical dullness was noted over right side of back. Abdomen soft, non-tender, bowel sounds auscultated in all four quadrants fields. No organomegaly noted.
Based on the exam findings you decide to order a chest x-ray (CXR) on Katie.
While waiting on the CXR results you review her chart more thoroughly. You note she was in for her annual exam one month ago and review her labs. All labs are normal, you note that her CMP results: BUN 19 mg/dl, Creatinine 0.9 mg/dl.
Her CXR report comes back: The CXR shows a dense shadow in the RLL.
After you are discuss the X-ray findings with Katie, she asks if you will “take a look” at her son’s elbows. Is there any cream he can put on it?
States he has itchy, dry flaky skin area on his elbows which started 2 weeks ago.
Patrick reports he has been picking at skin and it bleeds when he pulls off skin. He states he has been working a lot of overtime, feels really stressed and tired. He has been having tension headaches, taking NSAIDS almost daily for about 3 weeks. The ibuprofen seems to help the headaches a little He has used wife’s hand lotion on the dry skin but did not seem to make a difference. No new foods, soaps or detergents.
Additional interview responses: No reports of vision changes, ear pan, nasal discharge or sore throat. No reports of difficulty breathing, palpitations or heartburn. No history of health problems or join pain. The rash doesn’t really bother him, but his wife things it is unsightly. Has had a rash on elbows like this once before a few years ago but went away on its own. No surgeries. Previous hospitalization for broken leg requiring traction at age 8. No prescription medications. No herbal medication use. No reports of ETOH, tor illicit drug use. Smokes 1-2 packs/day. NKDA. Reports hayfever in the spring and fall. Immunizations are up to date. Works as a plumber. Sleeps 5-6 hours a night. Parents are deceased. Mother at age 51 from a brain tumor and father age 53 leukemia. Has one brother in good health.
Height: 5 feet 9 inches weight: 195 pounds T: 98.4, BP 130/78, P 76, R 20 Sao2 98%.
Alert, oriented and cooperative Eyes without exudate, sclera clear, PERRLA. Nares patent without exudate Heart RRR w/o murmur. Lung sounds are clear bilaterally. Tympanic membranes gray and intact with light reflex noted Skin: well-circumscribed deep red, scaling oval plaques noted to bilaterally elbows R>L. Scale is silvery white. No lesions noted on rest of body.
Discussion Part Two
Summarize the history and results of the physical exam for each patient in a separate SOAP note for each case study patient.
Calculate the BMI for each patient.
List the primary diagnosis with ICD 10 code. Include your rationale for choosing the primary diagnosis. The diagnostic rationale in the assessment section should include your patients’ symptoms, exam findings and the interpretation of all presented lab findings. Include one evidence-based journal article or clinical guideline that supports your rationale for each patient. Develop a complete evidence-based treatment (EBP) plan for each patient that includes medications, any additional diagnostic tests, patient education, possible referrals, and a plan for follow up with you, the PCP. Each step of the plan must include an in-text citation to an approved reference as listed on the Reference Guidelines document. The guidelines for SOAP note documentation is located under Course Resources and can assist you in writing this post and your SOAP note.