NU611 Clinical Decision Making
Unit 14 Discussion
Current Procedural Terminology
Instructions:
Review the SOAP notes accessed through this link.
(Links to an external site.)Current Procedures SOAP NotePreview the document
Construct a discussion that includes the following:
Identification of the procedures performed in each patient encounter
Assignment of CPT code for each procedure identified
Resources utilized for locating assigned CPT codes; if an online resource include the link to the site or page.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
The post and responses are valued at 20 points. Please review post and response expectations. Please review the rubric to ensure that your response meets criteria.
Estimated time to complete: 2 hours
Peer Response: Unit 14, Due Sunday by 11:59 pm CT
Current Procedural Terminology
Instructions:
Construct a response to at least 2 of your peers ideally one who located/utilized the same resource(s) for locating CPT codes for the identified procedures and one who did not.
Include in your response discussion your impression of the value of the resource(s) for your role as an NP.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
SOAP #1
Subjective:
Chief complaint: “I am here to have my Nexplanon removedâ€.
History of Present Illness: A twenty three year old white female, G0, obese presenting for Nexplanon removal. This
implant has been in place in her left arm since August of 2017, however, she desires its early removal due to
unintended weight gain and increased appetite, as well as uncontrollable mood lability. She does complain of
symptoms suggestive of yeast infection. She has had recurrent yeast infections to the vulva and vagina area,
otherwise she is doing well.
Past Medical History: She reports a history of headaches, dizziness, obesity, and yeast infections.
Surgical History: She reports having a genitourinary surgery, she has no details. She reports having an endoscopy in
November 2017 with gastritis.
Allergies: She reports an allergy to cephalosporins.
Medications: She is not currently on any medications.
Social History: She is single and lives at home with her parents. She works at an area convenience store as a cashier.
She denies the use of tobacco products or illicit drug use. She reports she occasionally has a drink when she is out
with friends. She denies any hobbies. She reports occasional intake of caffeine by way of soda and sweet tea. She
reports no history of sexually transmitted infections (STI’s).
Family History:
44 year old father is alive with no medical issues.
43 year old mother is alive with no known medical issues.
63 year old maternal grandmother is alive with hypertension (HTN).
65 year old maternal grandfather is alive with HTN, cardiovascular disease (CVD), and peripheral vascular disease
(PVD)
62 year old paternal grandmother is deceased with a massive myocardial infarction (MI)
63 year old paternal grandfather is alive with HTN, CAD, and a smoker.
Health Maintenance/Promotion: She reports that she is current on childhood immunizations. She reports a normal
Pap at the age of 21. She has had no other immunizations since she finished high school. She has not seen an eye
doctor in the last five years and she does not visit a dentist on a regular basis and has not been in the past three years.
She does not perform regular self-breast examinations.
Review of Symptoms:
General: She reports a weight gain of 27lbs since she had her Nexplanon inserted. She denies fatigue, fever, chills,
or night sweats.
Skin: She reports itching in her groin area. Denies rashes, lesions, dryness, moles, or hives. She denies nail bed color
changes, breast pain, lumps, or nipple discharge.
HEENT: She denies headaches, or hair texture change. She denies blurred vision, spots, dizziness, eye redness,
irritation, or drainage. She denies facial/sinus pain. Denies ear pain, hearing loss, vertigo, or drainage from ears.
Denies nasal drainage, epistaxis, or difficult with smell. Denies dry mouth, sore throat, hoarseness, or snoring. She
denies mouth, tongue, or teeth pain, denies mouth ulcers, dry mouth, or chewing and swallowing difficulties. Denies
bleeding gums. She is not aware of any dental carriers.
Neck: Denies neck or shoulder stiffness or swelling.
CV: Se reports no chest pain, chest tightness, orthopnea, or palpitations.
Lungs: Denies dyspnea, shortness of breath, cough, wheezing, bronchitis, asthma, sputum production, or
hemoptysis.
GI: She reports normal appetite, no heartburn, no dysphagia, no nausea or vomiting, no dysphagia. She denies
diarrhea, constipation, black or bloody stools or changes in bowel patterns. She denies abdominal discomfort or
distention, she has no food preferences and consumes a regular diet three times daily.
GU: Reports vaginal itching and a white discharge. She denies dysuria, hematuria, frequency, or abnormal bleeding.
She denies flank pain. She denies a vaginal discharge. Denies history of any sexually transmitted diseases.
PV: She denies varicose veins, temperature changes, edema, tingling, numbness, or discoloration to upper and lower
extremities.
MSK: Denies mouth, neck, jaw pain, back pain, or muscle stiffness. Denies difficult walking or climbing stairs.
Denies decrease in range of motion.
Neuro: Denies headache, dizziness, blackouts, tremors, weakness, numbness, speech problems, memory loss, loss of
consciousness, or seizures.
Endo: Denies hot and cold intolerance. Denies excessive thirst. She reports increase in appetite. Reports recurrent
yeast infections.
Psych: Denies depression, anxiety, or suicidal ideations. Denies sleep disturbances.
Physical Examination:
General: A 23 year old morbid obese white female, healthy in appearance whom is well developed, well nourished,
and well groomed. She appears in no acute distress. Ambulation noted to be normal. She is alert and orient to
person, place, time and situation.
VS: Temp-97.4*F (orally), B/P-128/80 sitting-L arm, HR-97 with regular rate, RR-20, Pulse Ox-97% on Room Air
at rest.
Weight – 353lbs, Height – 5′ 8″ with a BMI of 53.7
Skin: Round symmetrical face without atrophy. Warm and dry skin. Appropriate turgor with good elasticity noted,
no tenting. There are notice of rashes to bilateral inner thigh areas, beneath breast, and between abdominal skin
folds. There are no ulcers. Finger nails are normal in appearance.
Breast: No masses and no nipple discharge. Normal in appearance.
HEENT:
Head: No tenderness, lesions, or evidence of trauma, evenly covered with black shoulder length hair.
Eyes: The pupils are equally round and reactive to light and accommodation at 3mm bilaterally and non-injected.
Ears: The general external appearance of the ears appear normal. The external auditory canals have no drainage
present, the auricles are symmetrical. Tympanic membranes are pearly gray and landmarks are identifiable.
Nose: There are no external lesions, nares are patent and nasal turbinate’s are pink with no drainage. Midline
septum. There is no frontal or maxillary sinus tenderness.
Throat: There are no mouth, lip, or gum ulcers and no bleeding gums. Visible hard palate. No throat drainage and no
erythema. Tonsils visible.
Neck: There is good supply, trachea is midline, no thyromegaly. There is full range of motion of neck and shoulders.
There is no tonsillar, deep cervical, or posterior cervical node tenderness. No bruits and normal carotid pulses.
CV: There is normal S1 and S2 present with a regular rhythm and rate. There are no murmurs, rubs, or gallops.
There is no lower peripheral edema, clubbing, or cyanosis present and no calf tenderness.
Lungs: Symmetrical chest expansion, no dyspnea, wheezing, rales/crackles, or rhonchi. There is no chest wall
tenderness. Good air exchange with anterior and posterior lobes clear to auscultation.
ABD: Large soft, round, no tenderness, guarding, hernias or masses, no hepato or splenomegaly present.
Hyperactive bowel sounds present times four quadrants. There are no femoral or renal artery bruits auscultated.
There is no costovertebral tenderness. No flank pain.
GU: Visual inspection of vaginal area suggestive of candidiasis to inner and outer vaginal opening as well as the
entire vulva area.
PV: Good strong palpable peripheral pulses present. There is quick capillary refill no clubbing noted. There is no
swelling to upper or lower extremities. No varicosities. No temperature change between upper and lower
extremities.
MSK: Full ROM with normal gait and station. No deformities, normal curvature of back and no tenderness. Normal
tone and motor strength.
Neuro: Motor is 5/5 throughout. Bilateral hand grip equal and strong.
Psych: Good insight and judgement, Normal mood and affect, active and alert. Normal speech, tone, and voice.
Diagnostic Tests:
1. Urine pregnancy test – Negative
Diagnosis:
1. Surveillance of subcutaneous contraceptive implant
2. Recurrent candidiasis of vagina
3. Candida vulvovaginitis
PLAN:
1. Patient desires Nexplanon removal. She is aware fertility will resume very soon. She is refuses any form of
contraception at this time. Encouraged to use barrier contraception.
Procedure: Nexplanon was palpated by the physician and reveals to have been properly inserted. The skin area was
prepped with povodine Iodine. The insertion site was thin infiltrated with 1% lidocaine. A number 11 scalpel blade
was used to incise the skin, the implant was milked downward toward the skin incision and small Kelly forceps used
to grasp and remove the implant. Butterfly tape was used to close the incision. Dressing applied and patient was
advised to keep dressing in place for 24 hours and keep tape on incision for 48 hours. The patient tolerated the
procedure well.
Diagnostics: None
Therapeutic: None
Educational: Instructed to not remove the dressing to left upper inner arm for the next 24 hours and then could
change dressing if desired but to leave the tape covering the incision for a total of 48 hours. .
Consultation: None
2. There is recurrent candidiasis of vulva and vagina. It was noted today that it is suggestive of yeast under breast,
abdominal folds, and inner thigh areas, as well as the vulva and vagina. This is likely due to the severe morbid
obesity from excessive calories.
Will obtain blood draw for hemoglobin A1C and call with results.
Diagnostics: Hemoglobin A1C
Therapeutics: None
Education: Encouraged to start an exercise program by walking 30 minutes every day. Also encouraged an increase
in water consumption instead of soda’s. Offered nutritional consult for which she is declining at this time.
Encouraged to look at the DASH diet as well as other diets and handouts were given. Instructed that she could come
to clinic for weigh in if desired.
CONSULTATION: None at this time.
3. Candidiasis care instructions given, encouraged cool sits baths and to keep vaginal area dry. Will rexall
Fluconazole 150mg tablets for symptomatic relief and Nystatin topical cream. Again instructed that would call with
A1C results and schedule appointment if needed. Instructed to call or return to clinic if symptoms not improving on
day three or if worsening occurs.
Diagnostics: None
Therapeutics: 1-Fluconazole 150mg tablet – Take one (1) tablet every 72 hours by mouth. DISPENSE # two (2)
tablets with REFILLS: 0
2-Nystatin 100,000 unit/gram topical cream – Apply to the affected areas by topical route two (2) times per day for
one (1) week. DISPENSE# 1-30gram tube with REFILLS: 0
5
SOAP #2
SUBJECTIVE:
CC: “I am having pain with urinatingâ€
HPI: A 65 year old male presenting with complaints of having pain when he voids as well as lower abdominal and
back pain for the last three to four days. He states that is has been very uncomfortable for him to void. He states that
he will get intense cramping in his abdomen and feel like he needs to void but cannot. He reports he has been
drinking plenty of water and has taken sitz bath to help with voiding. He reports that once he can void the abdominal
and back pain resolves until he needs to void again. He states that he has not had any nausea or vomiting nor has he
had any blood in the urine. He reports that the back pain is the same back pain he was having before but more
intense when he has the abdominal cramping. He reports he tried the baclofen but had side effects from the
medication. He reports he did see his oncologist last week and was told that his kidney function and blood counts
were stable. He reports he had a CT scan of the abdomen and pelvis as well as chest done on 07/20/2019 and was
informed everything was normal. He reports he does have a urethral stent in place and has not seen his urologist
recently.
PMH: Colon Cancer stage 3 metastasized to liver and peritoneal, neuropathy that is secondary to chemotherapy,
urinary tract infections (UTIs), constipation, degeneration of lumbar intervertebral disc with low back pain.
Surgical history: Right ureter stent in January 2019, upper right chest port placement in 2017, appendectomy, hernia
repair with mesh, colonoscopy in 2016.
Allergies: no known drug allergies
Medications:
1-Flomax 0.4mg capsules one every 12 hours for to aid in urination, lactulose 10grams/15mL twice daily for
constipation, ibuprofen 200mg tablet – four every six hours as needed for back pain, Actifed over the counter (OTC)
as needed for runny nose, and Oxycodone 5mg tablets – one every six hours as needed for pain.
Social history: He is divorced and lives alone. He is also retired and enjoys spending time with his family and
friends. He enjoys the outdoors and fishing. He reports he was a former smoker but quit in the 1980’s. He reports
occasional alcohol intake, denies illicit drug use and reports a moderate amount of caffeine intake with coffee.
Family history: He reports his father is deceased with malignant tumor of prostate. Mother is deceased with heart
failure and paternal grandfather also deceased with malignant tumor of prostate.
Health Maintenance/Promotion: He reports he takes the influenza vacation and has had two pneumococcal vaccines
recently.
REVIEW of SYSTEMS:
General: A 65 year old Asian male reporting difficulty voiding, lower abdominal and low back pain. He reports no
chills, fever, night sweats or weight changes.
Skin: Denies changes to skin and denies any new lesions, rashes or dryness.
HEENT: he denies any head trauma, nodules or lesions to scalp. Denies headache, light-headedness, numbness or
facial pain. He denies blurred vision, spots or tearing. He denies ear pain, hearing loss, popping sound, ear drainage
or vertigo. He denies any present nasal discharge or epistaxis, He reported occasional seasonal sinusitis but has not
had any problem thus far. He denies difficult with smell or taste of food. He denies gum, lip, or mouth pain. He
reports upper and lower denture set. Denies throat discomfort or difficult swallowing.
Neck: Denies neck stiffness, swelling, or nodules.
CV: Denies palpitations, tightness or chest discomfort, edema, or shortness of breath.
Lungs: Denies cough, congestion, wheezing, shortness of breath or breathing concerns.
GI: Reports abdominal pain. Reports a mass to upper right abdomen that has not changed in size. Denies nausea,
vomiting, or diarrhea. He denies gastro reflux discomfort or indigestion. He reports occasional constipation. He
reports that his bowel habits have been unusual the last few days with having a normal bowel movement every four
to six hours while awake and he is denying clay, tarry, or black colored stools. Denies any recent bleeding disorders
or anemia. He reports his appetite has not been good the last few days.
GU: Reports lower right abdominal and flank pain, urine urgency and difficulty voiding, He reports sometimes there
is burning. He denies blood in urine.
PV: Denies cramps, numbness, and tingling. Denies swelling or varicose veins. Denies discoloration to nail beds.
MSK: He reports he has noticed an unsteady gait the last few days and finds himself holding on to something when
he initially gets up. He denies muscle stiffness or decrease range of motion. He denies any bony abnormalities or
joint swelling. He denies use of assistance devices.
Neuro: Denies memory loss, difficult speaking, dizziness, problems with concentration, or seizures. Denies
extremity tingling. Reports recent problem with walking. He denies problems with sitting or lying. He denies
generalized weakness.
Endo: Denies excessive thirst or hunger, hot and cold intolerance, excessive sweating, or thyroid dysfunction.
Psych: Denies anxiety, moodiness, depression, or suicide ideations.
OBJECTIVE:
Gen: A 65 year old responsible Asian male whom is well-nourished, well-developed, well-groomed, ambulating
normally whom appears to be chronically ill and in distress. He is orient to person, place, time, and situation.
VS: Temp-97.9*F (tympanic), B/P-119/67- R arm sitting, HR-91 bpm, RR-16, Pulse Ox-95% on Room Air
Weight – 190lbs, Height – 6’2″ with a BMI of 24.5.
PE: clear spoken words with strong thought process, current and remote memory unimpaired.
SKIN: Symmetrical face, tan in color, skin warm and dry, with good elasticity skin turgor noted to return on top of
right hand, multiple discolored spots and bruising noted to lower forearms. There are no open lesions or rashes
present to forearms.
HEENT: He is bald with no lesions, nodules or deformities to scalp. Bilateral eyes equally round at 2mm with pupils
reactive to light, white scleral and clear conjunctiva with no swelling, no ptosis noted, and extraocular movement is
present. There is no frontal or maxillary tenderness. External ear structures are normal with clear canals and normal
tympanic membranes and landmarks easily identified. Normal nasal mucosa, no obstruction to turbinate’s, no
external lesions, and no septal deviation. There is no nasal drainage. The lips are moist and pink with no lesions
present, no lesions at gums and no mouth ulcers. The tongue is symmetric, midline uvula, no erythema to posterior
pharynx. Midline trachea as well as thyroid, no swelling present and no tenderness on palpation. Neck is supple, no
cervical lymphadenopathy or tenderness bilateral, and no supraclavicular lymphadenopathy.
CV: Regular rate and rhythm with S1 and S2 present, no murmurs, rubs, or gallops and no carotid bruits. PMI
midline. No edema.
Lungs: Chest movement symmetric, clear bilateral breath sounds, good air exchange, no rales, rhonchi, or wheezing.
No axillary adenopathy.
ABD: Bowel sounds active and normal x 4 quads, soft, non-distended, no costovertebral angle (CVA) tenderness.
There is a small mass noted at the upper right quadrant with mild tenderness in lower abdomen on both lower
quadrants. There is no rebound tenderness or guarding. The liver and spleen are palpable and is non-tender. No renal
bruits. Patient declined rectal exam.
GU: Omitted
PV: No edema and no discoloration noted to lower extremities. No varicose veins. Radial, femoral, popliteal, and
pedal pulses present and strong. There is no discoloration of nail beds.
MSK: There was a slow irregular gait noted on moving from chair to exam table. However, there was normal motor
strength and muscle tone. His bilateral hand grip is strong and equal as well as leg pushes. No erythema. There is
lumbar tenderness present, and negative straight leg. There is no masses felt on lumbar region. There is no shoulder
drooping
Neuro: He does not appear to be anxious or agitated. There are no tremors present. He is able to move all extremities
symmetrical, finger to nose is intact. Reflexes present to patellar, biceps, triceps, and Achilles deep tendon. He
reveals normal speech, tone, and concentration.
Diagnostic Tests: Urinalysis, Dipstick with results of moderate leukocytes, moderate amount of bilirubin, and trace
of blood. Negative for nitrite, ketones, protein, and glucose, pH 7.0, specific gravity 1.005, urobilinogen 1.3, color
dark yellow, and , appearance is cloudy.
DIAGNOSIS:
1. Dysuria
2. Abdominal Pain
PLAN:
1-The urine dip stick is consistent with UTI. Send urine for culture and sensitivity. Will start on ciprofloxacin
500mg tablet one every 12 hours? Advise patient to increase water intake to 2000mL daily and to stay wellhydrated. Will give care instructions for painful urination. Instruct to notify if symptoms fail to improve within two
to five days. Discuss ER precautions.
Diagnostics: None
Therapeutic: Ciprofloxacin 500mg tablet – Take one (1) tablet every 12 hours by mouth for seven (7) days.
DISPENSE # 14 tablets with REFILLS: 0.
Education: Discussed the diagnosis and treatment plan to start ciprofloxacin and send urine for culture and
sensitivity. Instructed would call with culture results if a change in medication was needed. Instructed the need to
increase water intake and advised to stay well-hydrated. Painful urination care instructions given to patient.
Discussed the importance of calling or returning to clinic if symptoms not improved within two to five days and
discussed signs and symptoms that would warrant an emergency room visit. Instructed to continue all of current
medications.
Consultation: None
2- The abdominal pain is likely related to the underlying infection as well as his underlying colon cancer. Starting
antibiotic as listed above. Advised patient that if symptoms are not improving with several days that he may need
further workup. Instructed to keep up-coming follow-up with oncologist as well.
Diagnostics: None
Therapeutic: None
Consultation: Keep scheduled follow-up with oncologist.
SOAP #3
SUBJECTIVE:
CC: “I am having black stool and tirednessâ€.
HPI: A 68 year old white male presenting with complaints of black stool for the past two to three days whom
brought a sample into clinic today. He is also complaining of feeling “sluggish and fatiguedâ€. He reports no bad
smell or diarrhea. He became concerned when he noted a red ring forming when the stool “hit the waterâ€. He had
some muscleskeleton discomfort on 5/1/2019 for which he was prescribed Lodine. He reports he took it for one
week and then discontinued the use of due to problems resolving. He reports an uncomfortable feeling in the RUQ at
times describing it as just an achy feeling such as gas and relieved with movement. He reports no dyspepsia or
GERD. He reports no exacerbating factors. He reports taking no OTC medications for relief. He reports he had a
colonscopy in mid April, this year, and no polyps, but some diverticulosis. The stool brought in is dark and Heme
positive.
PMH: Chicken pox as a youth, hyperlipidemia and hypertension
Allergies: NKDA
Medications: He reports taking Amlodipine 2.5mg tablets daily for hypertension and an occasionaly daily
multivitamin for men. He reports he has not had to take any medication for hyperlipidemia for the past eight months
as he has controlled it with his diet.
Surgical history: Reports orthopedic surgery in January 2014 for dislocated left shoulder, from an incident with a
tractor rolling over, and colonoscopies in August 2011 and this May 2019.
Social history: Married with and self employed as a pastor and co owner in the new local ambulance service. He has
one 36year old son one 32 year old son. He reports he does not smoke nor has he ever, does not consume alcohol,
does not use illicit drugs nor has he ever. Reports heavy intake of caffeine with coffee four to five cups daily.
Family history:
67 year old wife alive with hypertension and seasonal allergies
36 year old son alive with ulcerative colitis
Father deceased with cerebrovascular accident
Mother deceased with congestive heart disease
Health Maintenance/Promotion: He reports he believs his child hood immunizations were received once he was an
adult. Received influenza injection September 2018. Had T-dap in 20170. He follows with his family physician
yearly and with cardiology. Has received the Hep B vaccine series in 2017. He had a yearly TB screening in
February 2019 which was negative. Received Pneumococcal vaccine at age 65. He reports he received the zoster
vaccine at age 62 on his birthday. He wears glasses with bifocals with the last exam being February 2019. He had
dental exam September 2018. Received colonoscopy May 2019. Does not exercise regularly. He is in the process of
assiting in building his new home.
REVIEW of SYSTEMS:
General: Denies fever, chills, night sweats, or weight change.
Skin: Denies skin rashes, lesions, dryness, or itching, reports scar to left shoulder.
HEENT: Denies headaches, migraines, head trauma, nodules to scalp. He reports frontal hair loss has been over the
past 20 years with recent changes to hair texture or finger nails. Denies light-headedness, reports occasional
dizziness upon standing for the past few days but quickly resolves. Denies any facial pain or numbness. Denies eye
discharge, spots, or double vision. Denies cataracts. Reports eye dryness with use of artificial tears occasionally.
Denies ear pain or drainage. Reports hearing loss in both ears. Denies nasal discharge, epistaxis or difficult with
smell. Denies throat pain or difficult swallowing. Denies tongue or gum disorder. Reports full upper and lower
denture set. Denies jaw pain.
Neck: Denies pain, lumps, or neck stiffness.
CV: Denies shortess of breath, dyspenia on exercertion, chest discomfort, tightness, palpitations, irregular heart beat,
murmurs, or edema. Denies orthopnea.
Lungs: Denies cough, wheezing, inability to take deep breath, or hemoptysis.
GI: Reports uncomfortable feeling to RUQ at times. Denies dyspepsia or reflux disease. Denies abdominal
distention, nausea or vomiting. Denies constipation or diarrhea. Reports black stools with red color. Denies excesive
humgry or thirst.
GU: Denies dysuria, hematuria, urinary frequency, decrease stream, or urgency. Denies flank pain or history of
kidney stones.
PV: Denies extremity swelling, tingling, or numbness. Denies clave tenderness. Denies hot or cold intolerance.
Denies bleeding disorders.
MSK: Denies joint or back pain, denies muscle problems. Denies arthritis. Denies unsteady gait or decrease in range
of motion.
Neuro: Denies sensory problems, weakness, stroke, seizures, tremors, or numbness. Denies problems with walking
or standing for periods of time. Denies history of falls. Denies memory loss.
Psych: Denies tension, nervousness, depression, anxiety, or suicidal ideations.
OBJECTIVE:
Gen PE: A 68 year old, well nourished, well-groomed polite white male with clear spoken words and strong thought
process with current and remote memory, decision, and cognitive making unimpaired. He is alert and oriented to
person, place, time and situation, in no acute distress.
VS: TEMP – 97.2, B/P – 129/83 sitting (L arm), P – 73, RR- 18, O2SAT – 99% (Room Air),
Height – 5ft 6in, Weight – 202lbs, BMI – 32.6.
SKIN: Warm and dry, face symmetrical pale in color, skin turgor with slight tenting noting lasting longer than three
seconds. No discolored spots, lesions, or rashes present to face, neck or lower forearms.
HEENT: Clean cut gray colored hair well managed with thinning to crown and frontal areas, no palpable nodules or
deformities to scalp. No maxillary tenderness. Masseter and temporal muscle strength noted to be equal upon smile.
Some skin looseness noted around mouth creases. Use of glasses noted. Eyes equally round and reactive to light
with bilateral pupil size at 2mm, white scleral and clear conjunctiva, ptosis noted bilateral otherwise exernal
structures appear normal. No periorbital edema, extraocular movement evident using pen and air H. Bilateral
external auditory canals free from drainage, tympanic membranes with no redness or bulging, landmarks are visible
bilateral. There is bilateral hearing loss noted with soft whisper voice. Nasal turbinate’s are clear, no lesions or
bleeding, no septum deviation, no obstruction. Mucus membranes moist and pink, no ulcers noted to gums, the gums
and tongue are moist and pink with proper movement, full set of dentures are noted. No exudate, lesions, or
erythema noted to throat area, uvula is midline. Trachea and thyroid are midline, neck supple and non tender, no
bruits, no submandibular, anterior cervical nodes, or posterior cervical nodes palpated. No shoulder drooping.
CV: Normal S1 and S2 with regular rate and rhythm, no murmurs, rubs, or gallop rhythms. PMI mid clavicular line.
Lungs: Bilateral symmetric chest excursions with normal appearing chest wall. Clear bilateral breath sounds with no
rales, rhonchi, or wheezing anteriorly or posteriorly. No retraction or signs of respiratory difficulty.
ABD: Soft, large, non-tender, non-distended abdomen with hyper active bowel sounds times four quadrants, no
ascites, no epigastric tenderness, no hernia’s or masses palpable, no hepatomegaly, flank tenderness, or
costovertebral angle tenderness. No renal bruits.
GU: Omitted
PV: No lower extremity edema or discoloration. No noticeable deformities. Radial and pedal pulses strong, equal,
and regular. No clubbing present.
MSK: No CVA tenderness, no defects or deformities noted. No erythema present. There is ability to bend and
extending back and waist. Good upright posture positioning and alignment present. There is full range of motion
noted. Equal bilateral hand grips strong.
Neuro: Gait is normal. No agitation or anxiousness present at visit. Deep tendon reflexes 2/4 symmetric triceps,
biceps, BR, and ankle. Motor 5/5 throughout, sensory intact with cranial nerves 2-12 intact. Good tone, moves all
extremities without difficult. Good mood and affect noted. Good speech and voice.
Diagnostic Tests:
1- Hemocult = positive
2- H/H revealing 12.3/37 and Platlet count of 269.
DIAGNOSIS:
1. Melena
PLAN:
(1) Melena – Likely with gastritis fom recent lodine use. There is no sign of volume depletion. Discussed results of
H/H and platlets. Check full CBC and CMP with GFR. Discussed management with PPI and Carafate. Get out
patient follow up with general surgery for consideration of EGD due to possible upper GI bleed.
DIAGNOSTICS:
Labs – CBC with auto diff, CMP with GFR
THERAPEUTICS:
1-Omeprazole 40mg capsule, delayed release – take one (1) capsule every day by mouth. DISPENSE # 90 capsules
with REFILLS- 0
2-Sucralfate 1 gram tablet – Take one (1) tablet four (4) times a day by mouth. DISPENSE # 60 tablets with
REFILLS – 0
EDUCATION: Instructed to take medication as directed. Instructed would review labs and call with results.
Discussed symtoms that would warrant an emergency department visit. Appointment made with General Surgery for
appointment on June 2, 2019 at 1:45pm. Encouraged to keep appointment. Instructed to continue medication
regimen of Amlodipine. Instructed to call or return to clinic with questions, concerns or worsening of symptoms.
Instructed to follow up in one month. Also discussed the importance of discussing weight loss possibilities on follow
up visit after GI consult.
CONSULTATION: General Surgeon for GI- possible upper GI bleed. Appointment obtained.
The post NU611 Clinical Decision Making
Un
