Dr Hansen an orthopedist, is seeing Andrew, a 72-year-old established male patient, today who has complaints of severe knee pain in both knees
Dr Hansen an orthopedist is seeing Andrew a 72 year old established male patient today who has complaints of severe knee pain in both knees and repeated falls over the past 2 months. Dr. Hansen completes a detailed history and exam with medical decision making of moderate complexity, including X-rays of each knee which show worsening osteoarthritis.
Because the patient has been experiencing repeated falls, Dr. Hansen provides the patient with an adjustable tripod cane with instructions for safe use. Dr. Hansen recommends the patient begin taking OTC glucosamine chondroitin sulfate, anti-inflammatories for pain as needed, and schedules the patient for a follow up appointment in one month. E&M code:__________________ ICD-10-CM code: ____________ ICD-10-CM code: ____________ CPT code: __________________ HCPCS code:
Dr Hansen an orthopedist is seeing Andrew a 72 year old established male patient Instructions
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NR601 Primary Care Mature & Aging Adults
Week 5 Assignment: Clinical Patient
Addendum to Directions:
This patient is your clinical patient for week 5. You are the Student NP Provider making decisions about your patient. This is not a group assignment. This is an individual assignment.
1). You must cite current Clinical Practice Guidelines for primary & secondary diagnoses. If there are 2021 versions you must cite 2021. No Exceptions
- You must cite 2 Scholarly Provider (NP, PA, MD, DO) Journal articles & at least 1 scholarly evidence-based journal article published in the last 5 years to support your work.
Textbooks, other books, .orgs, .edu’s, CDC, Stat Pearls & other websites cannot be cited. No Exceptions
- Medications: you must cite Online Prescribers Digital Reference (PDR) or CPG or Journal No Exceptions
Medication costs: You must cite Pharmacy Checker: https://www.pharmacychecker.com/drug- price-comparisons/#!. No Exceptions
Pharmacy Checker: Type in the medication, next page scroll to the bottom of the page, add quantity & your zip code to review the options for the lowest cost options. No Exceptions
4). This is your patient in a primary care clinical environment. You make the decisions in the role of NP provider using the Clinical Practice Guidelines & current evidence to provide Best Practice care. This is an individual assignment.
- 2 submission limit to Turnitin – Review policy No Exceptions 6). All submissions & TII reports are reviewed by your Professor
Clinic Patient
Chart 0002100
Week 5 Assignment: Clinical Patient Annika Chase Carter
75-year-old Female with complaints of a sore near her R ankle. She said it has been there since she worked in her rose garden about a week ago. She washed it with soap and water the day it happened.
Have you tried any OTC topical antibacterial ointments? No, nothing but soap and water once and a band aid.
It looks like a scrape. Dr Hansen, an orthopedist, is seeing Andrew, a 72 year old established male patient.Let’s have the MA cleanse the area. We will apply some Neosporin today and give you some samples to take home with a couple of band aids. If it is not better in 3 days, come back to the office.
Did we review your recent lab values last time you were her for an appointment?
No, I don’t remember talking about the labs. Is anything wrong?
Let’s start with the normal values and go from there and discuss next steps. General overview of patient: complete in outline document
Current medications: Vitamin D, OTC Capsaicin topical for L knee pain, 1st dose Pfizer COVID vaccine 2021.
PMH: Lap chole about 10 years ago, fractured ulna age 10 bike accident, 2 live births, NSVD.
FH: married 45 years, 1 daughter, no health issues, siblings: 1 sister endometrial cancer-survivor, Mother deceased breast cancer, Father deceased 68 years old unknown cause.
SH: Retired Xray Tech, no illicit drug use, drinks 1-2 glasses of wine weekends. No tobacco or illicit drug use.
Allergies: Penicillin/hives
Vital signs: BP 138/80; pulse 80, regular; respiration 18, regular Height 5’0, weight 180 pounds
HEENT: head normocephalic. Eyes clear without exudate. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Neck supple. Anterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
CV: S1 and S2 RRR no murmurs.
Lungs: Bilaterally clear to auscultation, respirations unlabored.
- Abdomen: soft, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits.
- No CVAT.
Derm: R ankle 2cm circular scrape with scab.
- +pedal pulses bilaterally
Laboratory Tests
| UA | pH 5.2 RBC (-)Leukocyte Esterase (-) Nitrates (-) Glucose (-) Protein Trace Ketone (-) |
| Complete Blood Count | RBC 4.92 million HGB 12.4gm/dl HCT 40%MCV 84 fl MCHC 32 g/dl RDW 13.6% WBC 4200/mm3 |
| CMP | NA+ 138K+ 4.2 Chloride 98 Glucose 99 BUN 12 Creatinine 1.00 GFR non-AA 94 mL/min GFR est AA 99 mL/min CA 9.5 Total Protein 7.7 Bilirubin total 0.6 Alk phos 74 AST 34 ALT 36 Bun/Creatinine 10 |
| Thyroid | Free T4 0.6 |
| TSH 2.05 | |
| HbA1c | 7.9% |
| Lipid Panel (fasting) | LDL-C 194 mg/dLHDL-C 50 mg/dL Total-C 236 mg/dL Triglycerides 132 mg/dL |
Also Read:
Diagnostics –
EKG: normal sinus rhythm
