Patient: S.B. Patient Demographics: Age: 72 y.o Sex: female Race: African American Subjective: CC: distressed, delusional, confused, extreme fear and anxiety HPI: S.B. is a 72-year-old AAF who was brought into the clinic by her nephew for the complaints of being in emotional distraught. Patient has been at her independent living facility for over 20 years. She is fully functional and independent. She provided care for her homebound husband with COPD for six years who recently passed away eight months ago as a result of respiratory arrest. Her only relative is her nephew who talks with her on phone about twice a month. Six weeks ago, her home was broken into, and she was raped and robbed. One of her church member who went visiting since they did not see her in one of the church function found her lying on the floor. She was down for two days and was taken to a local hospital. Here, she is distressed, delusional, anxious and in extreme fear. There are no signs of broken bones or rhabdomyolysis. SHx: Marital Status: widowed Children: One (passed) Occupation: retired hospital clark Living Quarters: independent living facility Tobacco use: Denies Alcohol use: Denies Illicit drug use: Denies PMHx: Pernicious anemia, osteoarthritis, and urinary incontinence PSHx: hysterectomy Allergies: penicillin Current Medications: Multivitamin one-a-day for women Cyanocobalamin (vitamin B12) 1000mcg Capsaicin topical cream 0.075% ROS: Systemic: Denies fever, chills, or recent weight gain/loss HEENT: Denies headaches, facial pain, or sinus pain. No earache, nasal discharge, nasal passage blockage, or sore throat. Cardiovascular: denies chest pain, palpitation, no awakening with shortness of breath, orthopnea, or limb swelling. Pulmonary: Denies wheezing, dyspnea on exertion, shortness of breath, or chest congestion. Abdomen: Reports decrease in appetite; denies nausea, vomiting or abdominal pain. Genitourinary: Reports incontinence; denies polyuria, dysuria, flank pain, or hematuria Musculoskeletal: Reports generalized body pain; denies limb or joint swelling. Neurological: confused by the situation, denies syncope, vertigo, dizziness, sensory disturbances, motor disturbances, gait abnormality, or speech difficulties. Psychological: reports excessive worry extreme fear and anxiety, and in emotionally distraught. Skin: Denies redness of the skin, itching, rash, lesions, or nail abnormalities. Objective Physical Exam General: BP 150/84, HR 99, RR 26, O2 97% RA, wt 121 pounds, ht 64 inches, BMI 20.8; Shows signs of extreme fear and anxiety, is fidgeting on the exam table. She is unable to stop crying, and is confused by what is happening. Neuro: AOx3. Confused about why she is in this state; Loss of ability to concentrate. No tremors. Normal gait. Cranial nerves: II-XII grossly intact. Unable to look provider in the eyes on examination HEENT: Head normocephalic with no lesions; Eyes PERRLA, EOMs full, conjunctivae clear, discs sharp and flat, no a/v nicking, hemorrhages, or exudates, normal visual acuity. EACs clear, TMs normal, hearing grossly intact bilaterally; external nose normal, mucosal, septum, and bilateral turbinates normal, no obstruction; The neck is supple, no masses, trachea midline; no thyroid nodules, masses, tenderness, or enlargement No thyromegaly, adenopathy, or bruits. Posterior pharynx without erythema or exudates. Cardiac: S1, S2, regular rhythm, no murmur, rub, or gallop; no thrill or palpable murmurs on palpation, no JVD, no displacement of PMI; no carotid or abdominal bruits; no enlargement of the abdominal aorta. Carotid, radial, posterior tibialis, and pedal pulses 2+ symmetric, no edema Respiratory: Lungs clear to auscultation on all fields, normal tactile fremitus, no egophony, tachypnea with no use of accessory muscles. Abdominal: soft, tenderness near the suprapubic area, and non-distended abdomen with no masses; BS normal, no liver nodularity or masses, no splenomegaly GU: Normal, no lesions, no discharge, no hernias noted Skin: diaphoretic, no rash, lesions, ulcerations, subcutaneous nodules or induration, Musculoskeletal: Normal ROM in all extremities and 4/5 strength, no joint enlargement or tenderness; no clubbing, cyanosis, petechiae, or nodes of digits and nails. Screening tools: (+) Primary Care PTSD Screen for DSM-5 Pelvic Exam- Pain exhibited during the examination. EKG- Shows sinus tachycardia X-rays- negative for fractures Labs- Pertinent Diagnostic Tests Notes: LABS Chem 10: Na 138, K 3.4, Cl 104, C02 27, BUN 9, Cr 0.7, gluc 100, Ca 9.8, Mg 1.4, PO4 2.3 CBC: WBC 4.3, Hb 13, Hct 32.9, plts 312. Lactate 1 mmol/L Question: The diagnosis for this patient is Posttraumatic stress disorder. What is the ideal treatment plan for this patient. Your treatment plan should address any national guidelines as appropriate for the diagnosis. 1. The final treatment plan will include the primary diagnosis, diagnostic testing recommended by National Guidelines. Medications, interventions, education, labs, follow up, referrals. After completing the treatment plan include the following sections in a large area called ANALYSIS: 2. Pathophysiology and Pharmacology: For the primary diagnoses in the case, write a brief summary of the underlying pathophysiology and tie pharmacological treatment chosen in the reversal or control of that pathology. 3. Additional analysis of the case: This includes national guidelines that were or should have been used to make diagnosis or treatment and review how they applied or how care was unique but based in guidelines. 4. Follow-up/Referrals: This means how the patient was doing when seen a second time if this applies. This would be their response to your plan of care. OR when Follow up will occur and what actions will be taken on the follow up visit. Referrals if indicated. 5. Quality: Include anything that should have been considered in hindsight or changes you would make in seeing similar patients in the future with the same complaint, history, exam, or diagnosis. Add anything you learned from discussion in the class that shed new light on this patient. 6. Coding and Billing. Any or all CPT and ICD-10 codes that should have been used (List them and name them only. Please ensure you address the questions above accordingly with full and substantial details and follow the rubric listed below: Rubric: Your response must be supported by evidence from appropriate sources published within the last five years (between 2014 and 2019). Focus of journal articles represents a logical link between the article content and the case study information. In-text citations and full references must be provided. Do not use textbook as reference. Discussion post presented in a logical, meaningful, and understandable sequence. Organization of topics and transitions among ideas lends clarity to the discussion. Headings and paragraph spacing are used logically and contribute to evidence of the assigned disease. Discussion post has minimal grammar, spelling, syntax, punctuation and APA* errors. No use of direct quotes. APA style references and in text citations are required;
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