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NU611 Clinical Decision Making
Unit 2 Discussion
New Patient Encounter
Instructions:
Review the SOAP note accessed through the link below.  For purposes of the assignment the patient is an ‘new patient’ in the practice.
New Patient SOAP NotePreview the document
Initial Post
Use your lecture materials to determine what CPT E&M Code to utilize for this ‘new patient’ encounter.
Provide justification for the code you assigned by including the following information in your discussion:
the level of history taking achieved – identify the history elements present
the type of exam performed – identify the number of systems and bulleted points in the note
the level of medical complexity encompassed – include # of points for a) diagnoses/management options, b) amount/complexity of data reviewed and c) level of risk for complications, morbidity, mortality
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 2, Due Sunday by 11:59 pm CT
New Patient Encounter
Instructions:
Consider the knowledge you have gained from this week’s lecture.
Construct a response to at least 2 of your peers commenting – ideally one who assigned the same CPT E&M Code that you did and one that did not.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
*Subjective
CC: chief complaint – “I have a rash that will not go away, and it is spreading.”
HPI: history of present illness –40 year old male presents today with a rash that he first noticed two months ago. He states the rash started on his chest, but over the last three weeks it has spread to his back and both arms. The patient says that the rash is dry, but not itchy. He denies any pain associated with the rash. The patient states that there is nothing that aggravates the rash. The patient has tried over the counter creams and lotions with no relive. The patient is concerned that the rash has been there for two months and is beginning to get worse.
PMH: past medical history –
Hypoglycemia – 2010
Allergies: NKDA
Medications:
Ketoconazole 2% External Shampoo. Apply to dampened skin, lather, and leave on for five min then rinse. Apply single-use daily for three days.
Social history:
Married
Current every day smoker
Alcohol: 6 pack beer daily
Recreational or chemical drug use: Denies
Exercise: None
Seatbelt use 50% of the time
Sun Exposure frequent
Family history:
Father Deceased, Cardiac issues
Mother Deceased, Cardiac issues, MI
Paternal grandmother HTN, Cardiac 78
Paternal grandfather Deceased Stroke 58
Maternal grandmother Diabetic type 2 age 75
Health Maintenance/Promotion:
Wellness Adult Exam/DOT physical (2018)
Flu (2018)
TD (2015)
Exercise none
Seatbelt 50% of the time
Review of Systems (ROS):
General: Denies, fatigue, fever, and night sweats. Denies anorexia, malaise, weight loss, weight gain, and sleep disorder
Skin: Complains of a dry rash to back, chest, and both arms that seem to be spreading.
HEENT: Denies blurred vision, double vision, halo, light sensitivity, eye irritation eye discharge, and eye pain. Denies ringing in the ears, ear discharge, earache, nosebleeds, difficulties swallowing. Denies hoarseness and sore throat Neck: Denies decreased ROM, pain with movement or difficulty swallowing
CV: Denies chest pain or discomfort, racing/skipping heartbeats or palpitations, lightheadedness, near fainting, fainting, shortness of breath with exertion, difficulty breathing while lying down and leg cramps with exertion
Lungs: Denies shortness of breath at rest, shortness of breath with activity, sleep problems related to breathing, wheezing, excessive sputum, coughing up blood and excessive snoring
GI: Denies indigestion, loss of appetite, nausea, vomiting, abdominal pain, bloating, gas, change in BM’s, diarrhea, constipation, blood with BM’s Hemorrhoids, and dark-tarry stools.
GU: Denies frequency, pain with urination, blood in urine, urinary incontinence or leaking, difficulty starting the urinary stream, difficulty emptying the bladder, and nighttime urination.
PV: Denies swelling, leg cramps, and coldness
MSK: Denies weakness, swelling, joint pain or stiffness, back pain, neck pain, muscle cramps, muscle stiffness, and gout
Neuro: Denies numbness and tingling, seizures, stroke, headache, tremors, memory loss or dizziness
Endo: Denies heat or cold intolerance, excessive thirst or excessive hunger
Psych: Denies trouble concentrating, nervousness, anxiety, panic attacks, mood changes, hearing voices, feeling unhappy, desire to harm self/others, sleep troubles, nightmares, memory loss, and stress
*Objective:
Physical Examination
VS:
Weight 197
Height 74.5 in
BMI 25.05
BP 130/86
Temp 98.9
PR 70
RR 18
Gen: On physical exam, the patient is alert and oriented in no acute distress.
Skin and hair: Hyperpigmented fine scaly macules that cover bilateral arms, anterior and posterior trunk. Edges are well defined, but the macules overlap.
HEENT:
Head: Symmetrically round, no lesions or bumps noted Face is oval and symmetrical
Eyes: No redness, discharge, or crusting noted to eyelids, Conjunctiva, and sclera are moist and smooth.
The sclera is white with no lesions or redness. Eyes are symmetrical.
Ears: Equal in size bilaterally. Skin is smooth, no lumps, lesions, or nodules noted. No drainage noted non-tender on palpations.
Nose: No deformity, discharge, inflammation, or lesions
Throat/Mouth: No deformity or lesions with good dentitions. Lips are moist and pink. The tongue is midline, moist and pink with normal movement
Neck: The neck is symmetrical with a centered head position and no bulging masses. The thyroid gland is nonvisible. The trachea is midline. No difficulty swallowing.
CV: Regular rate and rhythm. Apical pulse 70. No JVD noted
Lungs: Respirations 18/minute, relaxed, and even. Chest expansion symmetric. No pain or tenderness on palpation. Lung sounds are clear in all lung fields.
Abd: The umbilicus is midline with no bulging noted. The abdomen is flat and symmetric. No pain or tenderness on palpation. No guarding. Bowel tones are active in all four quadrants.
GU: No complaints patient reports voiding without difficulties
PV: No edema noted. No clubbing of fingers or toes. Capillary refill is less than 3 seconds. Skin is warm.
Pulses strong and equal. No visible varicosities noted.
MSK: Full ROM in both arms and legs. No weakness noted. Gait is smooth and steady. Extremities are symmetrical
Neuro: PERRLA, no tremors noted. The patient is alert and oriented
Psych: Alert and cooperative, normal mood and effect, normal attention span and orientation, memories intact
*Assessment:
Diagnosis
1. Tinea Versicolor B36.0
2. Alcohol abuse F10.10
*Plan:
1. Diagnostics: KOH prep obtained and shows fungal spores.
Therapeutic: Ketoconazole 2% external shampoo apply to dampened affected skin, lathered left on for 5 min then rinse. Apply single-use daily for three days. Dispense one bottle with one refill.
Educational: The patient was educated on the importance of using shampoo as prescribed. The patient was educated to decrease or stop drinking alcohol. The patient was instructed to follow up if the symptoms do not improve or if it gets worse.
Consultation/Collaboration: N/A
2. Diagnostics: N/A
Therapeutic: N/A
Educational: The patient was educated on the dangers of drinking while taking medication. The patient was educated on the possible affects on his liver. The patient was counseled to stop drinking or decrease amount.
Consultation/Collaboration: Quality Behavior Health

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