Healthy People 2030 Goals Assignment
Mr. D, a 74 year-old retired police officer, presents with Urinary frequency, urinary incontinence, dribbling and feeling of lower abdominal fullness. He’s by himself and a little forgetful so his PMH and Medication history is incomplete. Healthy People 2030 Goals Assignment
CC: “I had these peeing problems for months, they seemed to improve, and then got
worse. Now I’m getting scared.â€
Past medical history: Hypertension, BPH
Has been taking Flomax and cranberry pills, dose unknown, frequency everyday.
Physical exam: Blood pressure, 180/100; respiration rate, 18/min.
Patient states he was supposed to be taking Aldomet for his blood pressure but couldn’t have sex with it. Healthy People 2030 Goals Assignment
Physical exam is reported as negative for abnormalities.
Questions:
1.Subjective data: What subjective data should the APN obtain? How is the complaint investigated ie HPI?
This area should discuss history, ROS, and HPI format.
2. You will reassess to verify the presented information. For what additional objective data will you assess and why? Healthy People 2030 Goals Assignment
3. What co-morbid conditions should be investigated through the physical exam, how and why?
4. What National Guidelines are appropriate to this case? What do the guidelines state?
What level of evidence supports these guidelines?
5. What diagnostic tests will you order? Why do they apply to this case? What is the sensitivity and specificity? When it is positive or negative what does that mean? Healthy People 2030 Goals Assignment
6. What is your medical diagnosis? What are the differential diagnoses?
7. Treatment plan should clearly state what exact orders you are ordering. All medications must have a name, a dose, a route, and a frequency. The diet must be specific. The diagnostics must be specific. Do not say XRAY say type of Xray ie AP/Lat chest Xray Healthy People 2030 Goals Assignment
8. Are there any Healthy People 2030 goals that you should consider? How will you promote health with this case? How does it meet the 2030
9. What specific patient teaching is needed? Do not say “how to use an inhaler†state exactly what you will teach
10. What billing codes would you recommend? This must include the CPT code for outpatient office visits. ICD classify diagnoses ie HTN i10, CPT codes are 992–, Describe the difference between the first visit billing code and follow up billing code.
11. Follow up and evaluation. When will the next office visit occur? What will you assess? How will you revise the plan based upon this assessment? For instance, if you are assessing the HgbA1c and it is 9, what will you order? If it is 6.5 what will you do? Healthy People 2030 Goals Assignment