Caucasian male child, appears stated age, Alert and cooperative, appears tired and distracted. Skin: color is pale pink, no cyanosis or pallor
December 29, 2017
Calculate Patrick’s BMI, does the finding impact his diagnosis or treatment?
December 29, 2017

Question
Setting: large urban city

Family practice clinic which employs physicians and nurse practitioners.

Today is another busy in your family practice clinic. You note your next visit is a “2fer”. This means you have two patients to see in this visit. You ask your medical assistant to tell you why they are here. Your medical assistant tells you the patients are daughter and father. The daughter has burning with urination and the dad came along for the visit because he has some back pain. You review the chart before entering the room to familiarize yourself with these patients.

When you enter the room you note a Caucasian woman who appears to be about 40 years old. She is well groomed and appropriately dressed for the weather. She is sitting in the chair. The man is well groomed, appears to be about 70 years old, and is sitting on the exam table leaning forward. You introduce yourself as you always do and ask what brings them to the clinic today.

Mary

HPI

Reports burning with urination and feeling very itchy and uncomfortable in that area.

PMH

Age 44. No chronic illness or injuries. Recently treated for strep throat with a 10 day course of penicillin. Completed 1 day ago. Hospitalized x 2 for childbirth, no surgeries. NKDA. Drinks alcohol socially, denies tobacco or illicit drug use. Sleeps 6-7 hours/night. No current medications. Takes a daily multivitamin and a B complex vitamin.

Social history

Mary is married with four children ages 4-9. She works full time. Mary’s parents Katie and John also live in the home. Both are retired and help with childcare and household needs since both parents work full time. Her husband and father both smoke but not in the house.

Family history

Mary has 2 siblings who are in good health. Mother has a history of HTN, hyperlipidemia and osteopenia. Father has HTN and hyperlipidemia. They share their home with 2 dogs and a cat.

John

HPI

States he has had some back pain for three days that has not gotten better. He has taken Tylenol three times per day and though it takes the edge off it has not helped much and the pain is still there.

PMH

Age 75. Has HTN and hyperlipidemia. No previous injuries. No hospitalizations or surgeries. Takes Lipitor 40 mg daily and Lisinopril/HCTZ 20, 12.5 daily. Allergic to Bactrim. Sleeps 6-7 hours a night.

Social

Born in Ireland, has lived in America for 45 years. Lives with his wife in his daughter and son in laws home. Retired carpenter. Helps with the kids by taking them to school and after school activities. Enjoys gardening and fixing things around the house. Drinks ETOH on the weekends and smokes 1 pack a day. Denies other drug use.

FMH

Parents lived until their 80’s. Has 13 siblings, most are alive. One brother died suddenly of a heart attack age 45 and lost a sister at age 4 to consumption. No family health problems except for high blood pressure when they get older.

Discussion part one:

What further questions do you have forMary 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 literature. List 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, if any, would you order?
What further questions do you have forJohn 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 literature. List 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, if any, would you order?
Week 5: Discussion Part Two
77 unread replies.3434 replies.
Before proceeding with some delicate questioning about Mary’s condition you ask if she is comfortable discussing her condition in front of her father. Mary states she does not mind and continues the interview.

Mary

Interview: Her last menstrual period (LMP) was two weeks ago.

No reports of headache or vision changes. No fever, chills, nausea or vomiting. No ear pain. No reports of nasal congestion, or discharge No report of wheezing or shortness of breath. No reports of chest pain, palpitation, dizziness or enlarged lymph nodes. No reports of heartburn, or indigestion. Reports vulvar itching and burning with urination x 2 days. No reports of incontinence. No back pain. Feels “not right”. Is sexually active, denies dyspareunia. Has tried drinking more water, Monistat cream and cranberry pills. Nothing has really seemed to work, nothing makes it feel better.

VS

Height: 64 inches, weight 149 pounds BP 128/72, T 101.2, P 100, regular and R 14.

Focused exam

General: Alert, oriented and cooperative. Cardiopulmonary: Heart S1 and S2 noted, RRR, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. Abdomen soft, slight tenderness noted over suprapubic region, bowel sounds auscultated in all four quadrants fields. No organomegaly noted. No CVAT.

Labs: Urine dip: + leukocyte esterase. Small. Positive nitrites. Small blood. Trace protein, pH 7.0 specific gravity 1.020, negative ketones, and negative glucose. Urine HCG negative.

Based on reports of vulvar itching you perform a pelvic exam. Vulva with erythema and excoriation noted, most likely due to scratching. Urethra without swelling or discharge noted. Bartholin glands nontender, no enlargement bilaterally. Thick white curdy discharge noted in vagina, vaginal walls, erythema noted. Cervix pink, midline, smooth without excoriation, parous os, secretions cloudy, thick, stringy without odor. Bimanual exam: no pain with cervical palpation, uterus and ovaries not enlarged.

Wet prep: negative clue cells, positive hyphae. pH 4.0 Whiff negative

John

No fever, chills, nausea or vomiting. No ear pain. No reports of nasal congestion, or discharge No report of wheezing or shortness of breath. No reports of chest pain, palpitation, dizziness or enlarged lymph nodes. No reports of heartburn, or indigestion. Stated he has not had this back pain problem in the past, he does not remember an injury. It is difficult to stand up straight. Pain is in left lower back, no radiation. Pain is worse with standing and bending over. Pain is less when sitting. No reports of trouble with his bladder or bowels.

VS

Height 5 feet 7 inches weight 195 pounds T 98.4, BP 150/84, P 90, R 20.

Focused exam

General: Alert, oriented and cooperative. Cardiopulmonary: Heart S1 and S2 noted, RRR, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. Back: skin intact, warm and dry, no petecchiae, lesions or masses noted. Patellar reflexes brisk bilaterally. Normal spinal curvature. Tenderness noted upon palpation of left side lateral to lumbar spine. Straight leg raise is negative bilaterally. ROM: Unable to touch his toes, flexion is about 45 degrees. Gait is slow and appears unable to stand up straight, he is leaning forward slightly when walking.

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 ICD10 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.

 

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