Analysis of the Assessment D.E. had five diagnoses documented during the visit. Since she came for an annual physical exam, the primary diagnosis was female wellness exam. ICD-10 code was Z00.00. While she was in the office, she also complained of having one drop of vaginal blood every day after menopause. The second diagnosis was postmenopausal bleeding, and the ICD-10 code was N95.0. After D.E. was examined, wheezing sounds were auscultated and she has a diagnosis of COPD. The third and fourth diagnoses were breast abscess (N61.1) and COPD (J44.9). The last diagnosis is obtained during history taking: hyperlipidemia (E78.5). The reason to document other diagnoses than female wellness exam is to address all disease management and health …show more content…
According to the U.S. Preventive Services Task Force (U.S. Preventive Services Task Force, 2016), they found convincing evidence that bone measurement tests predict short-term risk for osteoporotic fractures in women who are 65 years and older. The tests should be performed every two years. The most common tests used are dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine. In addition, in postmenopausal women who have no previous osteoporotic fractures, the USPSTF also found convincing evidence that drug therapies reduce the risk for fractures. It is appropriate to recommend D.E. to take calcium and vitamin D3 for osteoporosis prevention, as she declined to have osteoporosis …show more content…
She also used motivational interview techniques to assess D.E.’s readiness for smoking cessation. Although D.E. was not ready to quit smoking yet, she did not seem to be resistant to the recommendation either. The revaluation of smoking cessation could be followed up on next visit. The student also used the “teach back” technique when she educated D.E. about heart-healthy lifestyle. D.E. was able to name a few activities and types of healthy food that she enjoyed. She also understood that smoking could affect her lipid level. If anything the student could have done differently was to ask more detailed questions about the reason she wanted to continue smoking vapor. Smoking was a major concern in D.E.’s life at this point, because she has hyperlipidemia, postmenopausal bleeding, and
UDS result: The patient recent was negative from all illicit drugs. Other: The patient is not interested in pursuing the mental health services at the moment as she expressed about not being ready for it at this time.
Chest x-ray showed no acute pulmonary findings. She was diagnosed with a viral syndrome. A follow-up visit was recommended. A visit note from Mary Grace Lasquety, MD (Internal Medicine), dated 05/22/2017, indicated that the claimant presented with headaches since the
In this instance, it appears that this testing was the most appropriate level of services, is likely to improve clinical outcome, and is recognized and generally accepted by the medical profession for the evaluation of this disease. Therefore, based on the clinical information provided for review and the current peer-reviewed medical literature, the genetic testing [CPT code 812929 – First Step Dx Plus Testing] that was performed on 02/29/2016 is not considered experimental and/or investigational. Based on the clinical information provided for review, the current peer-reviewed medical literature and the plan criteria, the genetic testing [CPT code 812929 – First Step Dx Plus Testing], which was performed on 02/29/2016 is medically necessary for the treatment of this member’s
Patient denies, fever, chill, vomiting, SOB, dysuria, frequency, or urgency. Due to symptom her PCM recommmend that she walk in during the hours of 11 yo 1130. Patient agreed and verbalized understaning to the POC.
Michaela P. Capulong NU 333-01: Physical Assessment for the Nursing Professional June 29, 2015 Journal 7 When I do my assessment on admission, I always include the assessment findings that I expect to be abnormal if the patient has definite cardiovascular problem. I notify the MD and the nurse practitioner immediately if I find abnormal findings or values. I ensure to chart the education and the correction in response of the abnormal findings. In addition to that, tests and labs should be done to rule out problems. It is essential to know the patient’s health history before conducting the physical exam.
In utilizing the instructional strategy, based on the social cognitive theory - lecture, quiz, games, and brain storming, the function shifts to an instructor, teacher, manager, and administrator. The function also shifts to a consultant or resource person to all the other members of the team – the Dietitian/Nutritionist, the Licensed Vocational Nurse, and the Fitness Instructor. The role also involves acting as a communicator, reporter, and advocate for health to the community. In conclusion, the roles are much more and encompasses a wider range, as the health education specialist wears many hats in the bid to reduce incidence of childhood obesity and adult onset of type II diabetes in Vista
ICD-10 diagnoses codes can have three, four, five, six, or even seven characters versus the five in ICD-9. Some of the new features found in ICD-10 are: Laterality Combination codes for certain conditions and common associated symptoms Combination codes for poisonings and associated external causes Character “X” used as a placeholder Two types of Excludes notes References BC Magazine. (2013, October 1). Terminology, anatomy and physiology: what is the real challenge in preparation for ICD-10?
Assessment and Diagnosis Ms. F is a 66-year-old African American female. She was most recently hospitalized complaining of nausea, vomiting, abdominal pain and decreased appetite; it was found that
Provide an example of how a “health coach” can help bridge the gap in the coordination of care for a patient with complex medical problems, and two reasons stated in the article why a patient may be more receptive to a health coach vs. a healthcare provider. A “health coach” can help bridge the gap in the coordination of care for a patient with complex medical problems in many ways. These health coaches can provide knowledge and support for patients who do not know how to properly manage their diseases/medical conditions. These coaches can also encourage patients to cut out bad habits (ex. Smoking) that cause their medical conditions to escalate. Health coaches can be extremely helpful in providing preventative care for patients that need guidance and assistance.
When this happened, they responded by feeling guilty, getting annoyed, or changing their help seeking behaviour. They were sceptical about power of doctors to influence smoking behaviour, especially since smokers already knew the risks they were taking with their health (8)(Butler et al. 1998). In a survey to compare perspectives of 57 practitioners and 30 lay (patient) participants of the service provision of nutritional advice, ‘…because different patients want different amounts of information…’ one practice nurse said (6)(McClinchy et al.
I strongly value my health and believe that health is our greatest form of wealth. When one lives a healthy lifestyle, it means more opportunities to explore the world, build families, achieving anything the heart desires and conquering personal goals. The behavior change philosophy fits my personal philosophy of health education the most because it involves goal setting, behavioral contracts and self-monitoring to help foster the modification of an unhealthy habit. The behavior change philosophy is very important because change is a process, not an event. Self-efficacy and motivation are key factors in successful behavior changes.
Review of Symptoms General: denies fever, night sweats, significant weight gain or loss, exercise intolerance, depression, sleep disturbances, or fatigue HEENT: denies dry eyes, irritation, vision changes, difficulty hearing, ear pain, sore throat, runny nose, or sinus pressure Neck: denies swollen glands or stiff neck Pulmonary: denies cough, wheezing, or shortness of breath Cardiovascular: denies chest pain or palpitations Gastrointestinal: denies abdominal pain, nausea, vomiting, diarrhea, constipation, acid reflux, or melena Genitourinary: reports dysuria and vaginal itching, denies incontinence, hematuria, increased frequency, abnormal bleeding, or vaginal odor Musculoskeletal: denies muscle aches, weakness, joint pain, back pain, or edema Integumentary: denies any rashes, lesions, or change in hair Neurological: denies numbness, headache, seizures, tingling or sensation changes Endocrine: denies bruising, excessive sweating, thirst, hunger, heat or cold intolerance Objective Data Physical Exam Vitals: blood pressure - 130/77, heart rate - 97, respiratory rate - 17, temperature – 97.9 , oxygen saturation –97% on room air, weight – 183 pounds, height – 5 feet 4 inches, body mass index –
The emergency room physician, David C. Lee, M.D., ordered medication, a series of diagnostic tests, and blood cultures, and he admitted Mrs. Adae to the hospital for further observation and testing, in order to rule out myocardial infarction and ACS. Dr. Lee listed "infectious etiology" in his differential diagnoses. Jennifer Bain, M.D., came on duty as an attending physician during the morning of June 29, 2006. Dr. Bain, an employee of UC, recorded her suspicion that Mrs. Adae 's chest pain was musculoskeletal. Dr. Bain noted that Mrs. Adae 's EKG, cardiac enzymes, and blood tests, with the exception of her elevated blood sugar, were normal.
The wellness of a human being has been broken down into five sections. These sections are: emotional wellness, intellectual wellness, physical wellness, social wellness and spiritual wellness. I think my strongest section for my personal wellness is my emotion, intellect and physical wellness. However, my weakest sections are social wellness and spiritual wellness. I believe that my emotional wellness is my strongest section.
The patient was diagnosed for polyps and multiple diverticula at the age of 68. The Patient suffers of painful osteoarthritis of both knees, shoulder hips. Patient?s mother deceased at the age of 79 from breast cancer and her father deceased at the age of 54 from heart attack. The patient noted with bilateral lower extremities edema, and claimed that she uses 2 pillows as a comfortable position to sleep,