NR 511 – Diagnosis with ICD10 code, evidence-based treatment (EBP) and SOAP note

Week 4: Discussion Part One

Setting: large urban city family practice clinic which employs physicians and nurse practitioners.

Your next patient is a work in for abdominal pain.

When reviewing the chart you see that this is Patrick Smith, age 42. You met him last month when he brought his mother-in-law in for a sick visit. You remember because you treated him as well for a skin condition.

You enter the room and introduce yourself again to Patrick. He is not the jovial man you met last visit; he appears to be uncomfortable as he reaches forward to shake your outstretched hand. NR 511 – Diagnosis with ICD10 code, evidence-based treatment (EBP) and SOAP note

Patrick says he is in a lot of pain. He thought it would go away but it is lasting and seems to be getting worse. He is also nauseous. He doesn’t think it is anything that he ate and no one at home has had the stomach flu. It is getting worse as he has been sitting in the office. He cannot find a comfortable position to sit.

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HPI

Woke up at 5 a. m. started out as pain on one side of his back. He thought he pulled a muscle. Now pain is spreading to his stomach and is getting worse. The pain sometimes shoots down into his groin. He feels nauseous. He seems to be going to the bathroom more often. He thinks he might have a fever because he has been sweating. NR 511 – Diagnosis with ICD10 code, evidence-based treatment (EBP) and SOAP note

PMH

Describes health as good. Has hay fever and psoriasis, medication which was given at last visit worked, not using at this time. No previous back injuries. No daily medications. No herbal medication use. Had his appendix out at age 10.. Previous hospitalization for broken leg requiring traction at age 8. Smokes cigarettes, a pack a day. No ETOH or illicit drug use. Sleeps 5-6 hours a night.NKDA. Immunizations UTD.

Social

Married, has four children. Lives with his immediate family and in-laws. Works full time as a plumber. Work has been so busy no time lately for regular exercise.

Family

Parents are deceased. Mother died at age 51 from a brain tumor and father died age 53 leukemia. Has one brother in good health.

Discussion Questions Part One:

• What further questions do you have for Patrick 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 or the textbook. 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 would you order?
• NR 511 – Diagnosis with ICD10 code, evidence-based treatment (EBP) and SOAP note

Week 4: Discussion Part Two

On further questioning Patrick has no report of further headaches, no fever, or vision changes. No report of nasal congestion, or discharge. No report of wheezing or shortness of breath with rest, palpitation, dizziness or enlarged lymph nodes. No reports of heartburn, or indigestion. Position changes and Tums did not relieve the pain, he did not try to take any other medication, he did not think he could keep it down if he tried because he is so nauseous.

Physical exam:

VS Height: 5 feet 9 inches weight: 198 pounds

T- 98.9, BP 160/96, P 100, R 22, oxygen saturation: 98%.

Reports current pain as 8/10. Describes back and stomach pain as throbbing. The pain seems come in waves and at time shoots down into his groin.

General

Alert, oriented and cooperative. HEENT: head normocephalic. Hair thick and distribution throughout scalp. Sclera clear, conjunctiva white.

Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. Cardiopulmonary: Heart S1 and S2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored.

Abdomen appears slightly distended, symmetric with no visible masses. RLQ scar noted. Decreased bowel sounds noted. No vascular sounds. Tympany noted in all four quadrants on percussion. Abdomen is soft, no organomegaly, no masses or tenderness. Positive CVAT on right side.

Urinalysis: Positive WBCs, Small blood. Trace protein, pH 7.0 specific gravity 1.030, negative nitrites, negative ketones, negative glucose. NR 511 – Diagnosis with ICD10 code, evidence-based treatment (EBP) and SOAP note

CBC: WBC 6000 mm3 RBC 5 million Hbg 15g Hct 46% MCV 90 fL MCHC 35 g/dL

You send Patrick to the in-house ultrasonographer. The report states “a 5mm smooth round calculus is noted at the junction of the ureter and the bladder:

Discussion Part Two:

Calculate Patrick’s BMI, does the finding impact his diagnosis or treatment?

Summarize the history and results of Patrick’s physical exam and then answer the additional case study questions below. NR 511 – Diagnosis with ICD10 code, evidence-based treatment (EBP) and SOAP note

List the primary diagnosis with ICD10 code. Include your evidence-based 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. NR 511 – Diagnosis with ICD10 code, evidence-based treatment (EBP) and SOAP note

Answer these additional questions in this post regarding this case:

What should the NP do if Patrick continues to come back for pain medication?

What are possible warning signs of prescription drug abuse?

List three of the twelve 2016 CDC recommendations that would help the provider in handling this case.