NURS 601B Week 7 Assignment Comprehensive H&P Case Study
NURS 601B Week 7 Assignment Comprehensive H&P Case Study
NURS 601B Week 7 Assignment Comprehensive H&P Case Study
It is the goal of this research paper to examine the significance of complete and accurate documentation of a patient’s medical history, including past and present illnesses and their associated tests, examinations, and treatments, as well as their outcomes.
Directions:
The first step is to:
Answer the following questions in APA format, using complete sentences and paragraphs, after you’ve read the full H&P.
Next,
Your paper should be formatted and cited in accordance with the most recent version of APA.
The paragraphs should incorporate your sources.
You can support your ideas with evidence from the literature by using internal citations that point to relevant sources.
A title page and a reference page should be included.
Thirdly,
To be safe, it’s a good idea to follow the 1997 CMS Documentation Guidelines for Evaluation and Management.
Look up the 1997 Guidelines of Documentation for Evaluation and Management on CMS.gov to find out what should go in a patient’s health record!
The following questions are for you to answer:
In accordance with CMS guidelines, does this document represent a complete history and examination?
What’s the point?
Make it clear what you’re looking for.
2. Examine the H&P and identify any mistakes.
Determine the H&P’s greatest assets.
After reading the H&P, do you have any questions that you are unable to answer?
Is the history consistent with the conditions listed in the assessment section?
What’s the point?
Give an explanation of why you believe what you believe.
If so, did you make a list of possible alternative diagnoses or conditions?
Is this the case? If so, please provide a list.
When searching for an ICD-10 code on CMS.gov, please include the following:
Acute exacerbation of moderate persistent asthma:
An infection of the lungs caused by an unidentified organism:
There are a number of causes of essential hypertension:
Unspecified hyperlipidemia
There are a number of factors that contribute to obesity.
Is it appropriate to bill for this visit with the ICD-10 code for pneumonia?
What’s the point?
Does this plan appear to be reasonable in light of the evaluations made?
What’s the point?
If the case study calls for it, identify three different ways to teach patients about their medications.
Include citations.
AHRQ’s recommendations for health promotion are broken down by age, gender, and other conditions.
Cite the sources you use in your writing.
The title and reference pages are not included in the recommended page count of 2-3 pages.
You must cite a minimum of two sources in your paper, excluding your own words.
Your paper should be formatted and cited in accordance with the most recent version of APA.
The paragraphs should incorporate your sources.
You can support your ideas with evidence from the literature by using internal citations that point to relevant sources.
A title page and a reference page should be included.
Docx file titled 601B: H&P guidelines
Anne Smith’s H&P is shown in full detail.
New patient Ms. Smith has arrived at an office-based internal medicine practice.
The H&P was written by Carly Sanders, a skilled nurse practitioner.
Anne Smith is the patient’s name.
The narrator is 55 years old.
2-14-2016 was the date of my visit.
This is a female
There is no better source of information than a patient who has been to the doctor in person to get it.
Subjective:
Following up after an emergency department visit is the most common complaint.
Reports indicate that she was treated for bronchitis in the ER about two weeks ago with an unknown antibiotic, which she has now finished.
A refill of Albuterol MDI was also prescribed.
Pt continues to complain of a cough and shortness of breath when exertion is involved. – Dr.
Since my last trip to the ER, my cough and shortness of breath have gotten no better.
It was reported that the cough was dry and present throughout the day and night.
Shortness of breath has been mildly alleviated by using Albuterol MDI 4–5 times daily.
The patient has had multiple bronchitis diagnoses in the past year and has been using Albuterol MDI multiple times a day for the last six months or more.
Hypertension, or PMH.
Bronchitis.
Hyperlipidemia.
Obesity.
HTCZ 25mg twice daily.
MDI q4h PRN Albuterol
Take 20mg of simvastatin once a day.
OTC Aleve 1–2 tabs taken as needed for headaches, if necessary.
Asthma: Codeine. Shellfish: Shellfish:
There is a family history of cardiovascular disease in both my mother and my father.
Asthma-infected son.
My hypertensive daughter.
Denies having DM in her family.
When her mother was diagnosed with breast cancer at the age of 40, she passed away a year later at the age of 44.
Clerical work: Retired from the position.
Widowed.
Adult children live with her and she helps out by babysitting their grandchildren.
Drugs, tobacco, and alcohol are not permitted.
System Analysis:
Reports a good night’s sleep, but a lack of energy.
Assumes there is no fever.
Palpitations are not listed on the CV.
Complications of pulmonary hypertension, including swelling.
PULM: (+) SOB when exertion is present.
A little wheezing.
(+) dry coughing.
Acute hemoptysis.
rhinorrhea is an ENT condition.
Pain/pressure in the sinuses is not included.
An earache or pressure. (-)
(-) I have a sore throat at the moment.
Objective:
CV: RRR, no sound.
All lobes of the lungs have bilateral posterior inspiratory wheezes.
It’s completely silent.
With percussion, there is no consolidation.
The chest rises and falls with equal amplitude at all times.
No extraneous muscle activity.
External ear tenderness or discharge is absent in patients with Bilat TM pearly-white ear canals.
Wet pink mucosa on the nasal mucosa.
There is no sign of a wound.
There was no discomfort in my sinuses.
Oral mucosa is pink and moist.
Grade 1 tonsils with no exudate.
A complete absence of lymphadenopathy is noted.
Caucasian woman with a large BMI.
Adequately affect.
He appears to be on edge.
Dressed appropriately.
There appears to be no physical abnormality on the face of this person.
Blood Pressure 140/90, Body Mass Index (BMI) 32, and Body Temperature 97.5.
Assessment:
Asthma with (acute) exacerbation of moderate persistence
Unidentified microorganism causing pneumonia
3. Primary hypertension (also known as essential)
4. An unspecified form of hyperlipidemia.
Obesity
Plan:
Dx Plan: There is no such thing.
Tx’s plan is to
Rx: Qvar 40mcg/spray, 2 puffs BID.
1-2 puffs of Albuterol MDI every four hours for wheezing.
The Inhalation Spacer Device is the prescribed medication.
With two refills, re-fill HTCZ 25mg PO BID #30.
2 refills of Simvastatin 20mg PO QD #30.