Professional Documents
Culture Documents
S: Subjective Data:
HPI: RL is a pleasant, 66-year-old Caucasian male who presents to the clinic for his
yearly physical. change his diabetic mediations due to the shots causing bruising from
his Warfarin therapy. Reports he noticed 3 weeks ago, that he has several bruises all
over his body from is diabetic shots. Denies any changes in his diabetic needles. His
medications have not been changed recently. Reports his last PT/INR was checked
last week and it was 2.9. He has no blood in his stool.
PSH: 1. Single chamber pacemaker placement with AV node ablation for a-fib (2014)
no complications.
2. TURP (2005) no complications,
3. Right Total Knee Replacement (2011) no complications,
4. Lap Cholecystectomy (2002) no complications.
SH: RL is married and lives at home with his wife. Patient has one brother and sister
along with one daughter and son. Patient lives in Dothan, AL. Patient graduated high
school and immediately went into the military. He is retired from the United States Air
Force for 25 years and was a machinist. Religious preference is Methodist. RL’s primary
insurance is Tricare for Life. He denies concern with cost of care. He denies any recent
travel. Patient reports he is heterosexual and only one lifetime partner and that is his
wife.
Erikson’s Stage: Ego Integrity vs. Despair. Patient states that he is satisfied with his
life and his accomplishments. He is proud of his service in the military and would not
change anything about his life.
ROS:
Constitutional Symptoms: Denies generalized health problems; weight loss; fever;
recent infection or change in activity level.
Eyes: Denies vision problems, poor eyesight, double vision, blurred vision, redness,
drainage, excessive tearing, pain, or trauma. Pt reports last eye exam was within
one year, no change in prescription. Wears trifocal lenses and glasses were last
adjusted at optomologist appointment in March 2018. .
Ears, Nose, Mouth and Throat: Ears: Denies problems including, presence of
infection or pain, vertigo, use of assistive hearing device. Nose: Patient denies
issues with sense of smell, discharge, obstruction, epistaxis, sinus trouble. Mouth
and teeth: RL had a dental appointment last month at which time he was re-fitted
for dentures as his previous set was ill-fitting. RL reports brushing once daily and
nightly use of Efferdent to clean his dentures overnight. Pt denies issues with
bleeding of gums, problems with sense of taste, mouth odor or ulcers, or sore
tongue. Throat: Patient denies sore throat, hoarseness, dysphagia.
Cardiovascular: Denies any current cardiac issue, abnormal heart sounds, chest pain,
palpitations, high or low blood pressure, edema, claudication or varicose veins.
Respiratory: Denies cough, previous TB exposure, difficulty breathing, wheezing,
hemoptysis, sputum production or night sweats, or dyspnea on exertion.
Gastrointestinal: Denies issues with nausea, vomiting, food aversion, diarrhea,
abdominal pain, flatulence, change in bowel pattern, black/bloody stools,
hemorrhoids, jaundice or rectal pain. Denies constipation.
Genitourinary: Denies nocturia, dysuria, discharge, pain, incontinence, or problems
with the penis and testes.
Musculoskeletal: Denies neck pain or stiffness, or swelling, incapacitating back pain,
paralysis, deformities, changes in range of motion of activity, or injury. Reports
occasional joint pain in the hands and hips from his rheumatoid arthritis “reports
this is normal for him” that is relieved with OTC Aleve.
Integumentary: Denies noticing lumps, pain, discharge, or dimpling anywhere on the
skin, changes in skin, rash, itching, nail deformity, hair loss, new moles, open
areas. Reports easy bruising related to self-injection sites.
Neurologic: Denies muscle weakness, dizziness, syncope, stroke, seizures,
paresthesias, involuntary movements or tremors, loss of memory, severe
headaches. Reports neuropathy is not self-limiting and is well-controlled with oral
Gabapentin.
Psychiatric: Denies nightmares, mood changes, depression, anxiety, nervousness,
insomnia, suicidal thoughts, potential for exposure to violence. Pt reports feeling
safe at home.
Endocrine: Denies thyroid problems, cold or heat intolerance, polyphagia, polyuria,
changes in skin, hair or nail texture, unexplained weight change, changes in
facial or body hair, change in hat or glove size, use of hormonal therapy. Labs
Oct 2018- FSBS 110, HgbA1c 7.2%
Hematologic/Lymphatic: Denies unusual bleeding, history of anemia, history of blood
transfusions, swollen and/or tender glands. Reports bruising “from that Warfarin.”
Denies any blood in stools or bleeding from gums. October 2018 INR 2.9.
Allergic/Immunologic: Denies seasonal allergies; no previous allergy testing. Flu and
pneumonia vaccine were received October 2018.
O: OBJECTIVE DATA:
Constitutional – RL is a pleasant, well-dressed male who is sitting on the exam table.
VS: BP 110/70 Left arm sitting with adult cuff, HR 86, Temp 97.5 oral, RR 18, SPO2
98% on RA, height 75”, weight 269.5lb BMI 33.7 obese.
Head, Eyes, Ear, Nose, Throat, Neck: Head: Normocephalic, atraumatic, no visible
palpable masses, or scarring. Hair evenly distributed .PERRLA, EOM intact, red
reflex is present upon examination, no hemorrhage or exudate noted bilaterally.
External ears are normal bilaterally. TMs are easily visualized, intact and pearly
grey bilaterally. No bulge, erythema or exudate noted. Hearing is present and
WNL bilaterally. External nose/nares are normal bilaterally without lesion or
deformities noted upon inspection. Nasal mucosa and turbinates are clear
bilaterally, septum is midline. Teeth are absent, dentures are in place and fit
well. Tongue and uvula are midline, posterior pharynx is clear, pink and without
erythema or exudate. Negative for halitosis. Neck: No noticeable or palpable
swelling. No meningeal signs including nuchal stiffness. Unable to appreciate
thyroid gland upon palpation.
Cardiovascular: S1 and S2 are present bilaterally. Regular rate and rhythm with no
murmur, rub or gallop appreciated. PMI is mid clavicular line, 5th ICS. No JVD
present, no carotid bruit present. Capillary refill 2-3 seconds, +2 pedal pulses
bilaterally.
Respiratory: Lungs are clear to auscultation bilaterally throughout all lung fields,
anterior and posteriorly. No use of accessory muscles, no adventitious lung
sounds noted.
Gastrointestinal: Abdomen is soft, round, obese, non-tender and non-distended.
Bowel sounds present x4 quadrants. Light and deep palpation are without
guarding or rebound tenderness. Liver edge, spleen and kidneys not felt. Liver
span 10cm by percussion. I was unable to appreciate any masses upon deep
palpation.
Genitourinary: Deferred today. Last PSA (4.0) was done in Dr. Patel’s office in June of
this year. Patient is followed there for history of prostate cancer.
Musculoskeletal: Normal ROM, strength and grips equal bilaterally. Patient is able to
lie down and sit up from the exam table without difficulty. No swelling, erythema
or crepitus noted to joints. Spine is midline. Negative straight leg raise.
Integument: Skin is supple and intact. No rashes, lesions, subcutaneous nodules,
indurations or ulcerations noted. No nail bed clubbing, peripheral/central
cyanosis, or petechiae noted. Multiple bruises of different sizes and shapes
ranging from 1mm to 3mm scattered on back of arms bilaterally and front of
bilateral thighs in different stages of healing.
Neurologic: Alert and oriented x3. Short and long term memory intact. No tremors or
involuntary movements.
Cranial Nerves:
I Olfactory-Identifies correct smells
II Optic - Corrected visual acuity 20/20 bilaterally, visual fields full; optic disc
sharp with venous pulsations present bilaterally.
III-oculomotor, IV- trochlear, VI- abducens- pupils 4mm and reactive to light,
extraocular movements intact; no ptosis.
V trigeminal- Facial sensation equal to pinprick in all 3 divisions bilaterally.
VII Facial - Face symmetric with normal eye closure and smile.
VIII Vestibulocochlear- Hearing normal to rubbing fingers.
IX Glossopharyngeal, X Vagus- Palate elevates symmetrically; phonation is
normal.
XI Accessory- shoulder shrug equal bilaterally.
XII Hypoglossal -Tongue midline with good movements and no atrophy.
Motor- Normal bulk, tone, and strength noted to bilateral upper and lower
extremities, no pronator drift.
Sensory- Vibration felt in toes and fingers bilaterally; pinprick intact in feet without
distal gradient.
Reflexes- 2+ and symmetric at biceps, triceps, knees, and ankles; plantar
responses flexor bilaterally.
Coordination- normal fine finger movements, finger-nose-finger, and heel-knee-
shin.
Gait- Steady with normal steps, base, arm swing, and turning; normal heel, toe
and tandem walking.
Psychiatric: Judgement is appropriate for the patient, mood and affect are appropriate.
No obvious depression, anxiety or agitation.
Hematological/Immunologic/lymphatic: Negative for petechia or abnormal bleeding.
Noted throughout entire body. Multiple bruises, see integumentary No cervical,
post-auricular, clavicular, or inguinal lymphadenopathy noted.
DIAGNOSTIC TESTING:
Blood glucose (82962) and Hemoglobin A1c (83036) - to evaluate effectiveness
of patient’s current medication regimen (Resulted 180 fasting Blood sugar and
7.2 A1c.
INR (85610) - To evaluate therapeutic effect of Warfarin (pending).
CBC with differential (85007)- Routine for annual screening examination
(pending).
CMP (10231) - Routine for annual screening examination, also evaluate renal
function in the patient with known diabetes who chronically uses NSAIDs for
arthritis pain. Calcium, magnesium and phosphorus levels are may be altered in
the patient with cardiac history and history of chemotherapy. (pending)
Lipid profile (80062) - Routine for annual screening examination (pending).
TSH (35267) - Routine for annual screening examination and to evaluate thyroid
function in the elderly patient (pending).
Obtain baseline EKG (93042) from cardiology office- for PMD record (received)
C-Peptide ( 8046) to evaluate if patient is truly a type II diabetic (pending).
A: ASSESSMENT/ANALYSIS:
DIFFERENTIAL DIAGNOSES
1. Z00.01- Encounter for routine adult medical examination with abnormal
findings.
o Supportive- AgbA1c is 7.2
2. Z01.419- Encounter for Gynecological exam.
o Refuted- male sex
3. Z71.89- Encounter for travel physical
o Refuted- patient not traveling.
4. D68.32- Hemorrhagic disorder due to extrinsic circulating anticoagulants
o Supported- excessive bruising
4. R23.3- Spontaneous ecchymosis
o Refuted- patient on anticoagulant
5. D68.9- Coagulation defect
o Refuted- Patient is known to be on an anticoagulant
DEFINATIVE DIAGNOSIS
Z00.01- Encounter for routine adult medical examination with abnormal findings.
D68.32- Hemorrhagic disorder due to extrinsic circulating anticoagulants
ORGANIZED LIST:
1. Acute self-limited problems
Bruising- M79.81
2. Chronic health problems
HTN – I10
o Medication- Lisinopril 10mg by mouth daily
o Treatment- ACE inhibitor
o Education-
Reduce sodium intake to no more than 100mmol/day
weight loss
limit alcohol intake to no more than 0.5oz of ethanol per day
maintain adequate intake of dietary potassium
maintain adequate of calcium and magnesium for general health
stop smoking
Engage in aerobic exercise at least 30 minutes daily for most
days
Monitor blood pressure readings at home
Common Side effects of medication
dizziness, faintness, or lightheadedness when getting up
suddenly from a lying or sitting position
blurred vision
unusual tiredness or weakness
o Diagnostic- CMP
3. Health maintenance
Nutrition-
o Choose a diet low in fat, saturated fat, and cholesterol
o Choose a diet with plenty of vegetables, fruit, and grain products
o Use sugars in moderation
o Use salt and sodium in moderation
o If you drink alcoholic beverages, do so in moderation
Weight loss
o Follow a healthy diet, and if you are overweight or obese, reduce
your daily intake by 500 calories for weight loss
o Stay physically active
o Limit the time you spend being physically inactive
Exercise
o Exercise in water such as swimming and/or hydro classes are
excellent activities that provide a cardiovascular or resistance
workout while supporting the body weight
o Begin exercising for 10 minutes or less and when the patient feels
comfortable increase the exercise duration to 11 minutes, then 12
and so on until the desired recommended times are achieved
Vaccinations-
o Influenza (Flu): Yearly flu vaccine
o Zoster (Shingles): Vaccine for adults at age 60
o Pneumococcal (Pneumonia): At least two vaccinations (injections)
one year apart beginning at age 65
o Tdap/Td (Tetanus, Diphtheria and Pertussis/Tetanus and
Diphtheria): Every 10 years.
P: Plan:
Z00.01- Encounter for routine adult medical examination with abnormal findings
1. Diagnostics-
1. Blood glucose (82962) and Hemoglobin A1c (83036)
2. INR (85610)
3. CBC with differential (85007)
4. CMP (10231)
5. Lipid profile (80062)
6. TSH (35267)
7. Obtain baseline EKG (93042)
8. C-Peptide (8046)
2. Treatment-
Medications- Metformin
o Diabetes Mellitus Type 2
MOA- Decreases hepatic glucose production, decreases
intestinal absorption of glucose, and improves insulin
sensitivity by increasing peripheral glucose uptake and
utilization.
Usual Dosage- 500mg my mouth twice a day
Availability
Generic Name: Metformin
Brand Names: Fortamet, Glucophage, Glucophage
XR, Glumetza. Riomet
Cost- Generic Metformin
Publix (Dothan, Al)- Free, 30-day supply
Winn-Dixie (Dothan, Al)- $3.00 for a 30-day supply
Wal-Mart (Dothan, Al)- $4.00 for a 30-day supply
Diagnosis specific treatment
o Exercise or specific activities-
Aerobic – walking, jogging/running, tennis basketball,
swimming or biking for 30 minutes or longer 3 days a week
Strength Training- lifting weight for 20-30 minutes at least 2-
3 times a week
Flexibility training- stretching exercises 2-3 times a week
o Diet or diet modifications
Foods to eat for a type 2 diabetic diet include complex
carbohydrates such as brown rice, whole wheat, quinoa,
oatmeal, fruits, vegetables, beans, and lentils. Foods to
avoid include simple carbohydrates, which are processed,
such as sugar, pasta, white bread, flour, and cookies,
pastries.
o Home Monitoring/treatment
Daily glucose checks
Daily blood pressure checks
Diabetic diet
3. Education-
Health Promotion-
o Implement combined diet and physical activity promotion programs
to prevent type 2 diabetes for people at increased risk. These can
include counseling, coaching, or a combination of both.
o Develop case management interventions to coordinate and provide
healthcare for all people affected by diabetes.
o Engage community health workers in diabetes prevention
programs to improve glycemic control and weight-related outcomes
for people at increased risk for type 2 diabetes.
o Develop intensive lifestyle interventions for patients with type 2
diabetes to improve glycemic control and support dietary
modification, regular physical activity, and weight management.
o Develop team-base care interventions to help patients manage
type 2 diabetes and improve blood glucose, blood pressure, and
lipid levels.
Health Maintenance/safety Issues-
o A1c- target < 7% or lower if not having significant hypoglycemia
o Blood pressure - target < 130/80
o Foot exam and foot care
o Fitness plan/ways to be active
o Stress management
o Keep daily blood sugars within normal range
Signs and symptoms of hyperglycemia
Increased thirst
Headaches
Trouble concentrating
Blurred vision
Frequent peeing
Fatigue (weak, tired feeling)
Weight loss
Blood sugar more than 180 mg/dL
Signs and symptoms of hypoglycemia
Confusion
Dizziness
Feeling shaky
Hunger
Headaches
Irritability
Pounding heart; racing pulse
Pale skin
Sweating
Trembling
Weakness
Anxiety
Disease Prevention-
o Watching your weight
o Eating healthy
o Staying active
4. Consultation/ Referrals-
None at this time.
5. Follow-up-
Specific Instruction
1. 4 weeks for evaluation of medication changes (as a Nurse Practitioner I would
bring the patient back in a week)
2. If patient experiences hypoglycemia or hyperglycemia, notify the healthcare
professional immediately.
Acute Problems
1. If daily Blood Sugars and A1c levels do not remain in therapeutic range, may
need to refer to Endocrinologist.
Chronic Health Problems
1. Maintain regular scheduled appointments with Dr. Doty (PCP) for management of
Hypertension, DM2, sleep apnea and rheumatoid arthritis.
2. Maintain regular scheduled appointments with Dr. Aliabadi (Cardiologist) for
management of A-Fib and Pacemaker.
3. Maintain regular scheduled appointments with Dr. Patel (Oncologist) for
management of Prostate Cancer.
1. Diagnostics-
1. Blood glucose (82962) and Hemoglobin A1c (83036)
2. INR (85610)
3. CBC with differential (85007)
4. CMP (10231)
5. Lipid profile (80062)
6. TSH (35267)
7. Obtain baseline EKG (93042)
8. C-Peptide (8046)
2. Treatment-
1. Medications- Discontinued Warfarin 2.5mg M, W, F and 5mg T, TH,
Sat.
Indication for this patient- Patient had a history of uncontrolled A-fib
until 2014 when a pacemaker and ablation were performed. Up
until then he was put on anticoagulation therapy which was causing
excessive bruising from his diabetic shots.
MOA- Warfarin competitively inhibits the vitamin K epoxide
reductase complex 1 (VKORC1), which is an essential enzyme for
activating the vitamin K available in the body. Through this
mechanism, warfarin can deplete functional vitamin K reserves and
therefore reduce the synthesis of active clotting factors.
Usual Dosage- 2-5mg by mouth daily for 2 days, then check
PT/INR and adjust dosage depending on results.
Availability- generic (Warfarin) Brand name (Coumadin, Jantoven)
Based on the 5mg dosage (Warfarin)
Wal-Mart- Dothan, AL $4.00 for a 30 day supply
Winn-Dixie- Dothan, AL $4.00 for a 30 day supply
Publix Dothan, AL $7.50 for a 30 day supply
2. Diagnosis specific treatment
Exercise
Stroke Prevention
Any amount of exercise will help, but if you can
manage it, you should aim to do at least 30 minutes of
moderate physical activity five or more times a week.
You don’t have to do all 30 minutes at once, it can be
broken up into smaller blocks of time throughout the
day.
Home monitoring/treatment
Signs and symptoms of stroke
weakness on one side of the body
numbness of the face
unusual and severe headache
vision loss
numbness and tingling
unsteady walk
Signs and symptoms of DVT
Swelling in one or both legs
Pain or tenderness in one or both legs, even if it's just
when you stand or walk
Warm skin on your leg
Red or discolored skin on your leg
Veins that are swollen, red, hard, or tender to the touch
you can see
Signs and symptoms of Pulmonary embolism
Sudden shortness of breath
Chest pain-sharp, stabbing; may get worse with deep
breath
Rapid heart rate
Unexplained cough, sometimes with bloody mucus
Prevention of excessive bleeding
Use a soft bristle toothbrush
Shave with an electric razor rather than a blade
Use caution when handling sharp objects (shaving
razors, knives)
Avoid activities that could result in injury (eg, contact
sports)
Use appropriate safety equipment (eg, helmets,
padding) during physical activity
Avoid aspirin or other non-steroidal anti-inflammatory
agents (NSAIDS) (eg, ibuprofen [sample brand
names: Advil, Motrin] and naproxen [sample brand
name; Aleve]) unless your healthcare provider tells
you to take them. Other non-prescription pain
medications, such as acetaminophen, may be a safe
alternative.
3. Education-
1. Health Promotion
a. Lifestyle changes, such as increasing physical activity, need to be tailored
to each individual, with consideration of stroke-related deficits.
b. Interventions with stroke survivors to increase awareness of risk and
manage risk factors over the long term, such as education, written
materials, behavior modification, and stroke nurse specialist follow-up,
have shown modest effects.
c. Empowering patients to succeed in goal-setting around healthy lifestyle
choices has proven to be an effective strategy.
2. Health Maintenance/safety issues
a. Strengthening leg muscles and balance through exercise
b. Wearing flat, wide-toed shoes
c. Eating calcium-rich foods and taking calcium supplements to increase
bone strength if necessary
d. Following your therapists’ recommendations about limitations and walking
needs
e. Not relying on furniture for support while walking. Use assistive devices
prescribed by your therapist
f. Recognizing that certain medicines may make you drowsy and taking
precautions
g. Limiting walking when distracted
h. Never walking without prescribed aids such as braces or canes
3. Disease Prevention
a. Lower Blood Pressure
b. Stay away from smoking
c. Manage your heart rhythm
d. Limit alcohol
e. Control your diabetes
f. Exercise
g. Eat healthy
h. Watch cholesterol
i. Keep sleep apnea under control
j. Medication compliance
k. Aspirin a day
4. Consultation/Referrals-
1. None at this time.
5. Follow-up-
Specific Instructions
Recheck PT/INR in 4 weeks (as a Nurse Practitioner I would bring
patient back in a week)
Acute Problems
Educate patient if bruising or bleeding gets worse, notify the health
care professional immediately.
Educate patient if he has any signs or symptoms of stroke, DVT, or
pulmonary embolism call 911 immediately.
Chronic Health Problems
Maintain regularly scheduled appointments with Dr. Doty (PCP) for
management of Hypertension, DM2, sleep apnea and rheumatoid
arthritis.
Maintain regularly scheduled appointments with Dr. Aliabadi
(Cardiologist) for management of A-Fib and Pacemaker.
Maintain regularly scheduled appointments with Dr. Patel
(Oncologist) for management of Prostate Cancer.