Analyze the case study assigned to you at the outpatient clinic. Create a holistic care plan for disease prevention health promotion and acute care of the patient in the clinical case.
Genitourinary Clinical CaseHide orderOrder DescriptionAnalyze the case study assigned to you at the outpatient clinic. Create a holistic care plan for disease prevention health promotion and acute care of the patient inthe clinical case. Your care plan should be based on current evidence and nursing standards of care. Scholarly article within last 5 years.Next determine the ICD-9 classification (diagnoses). The International Classification of Diseases Ninth Revision Clinical Modification (ICD-9-CM) is the officialsystem used in the United States to classify and assign codes to health conditions and related information.Search term page to identify the codes applicable to the care plan. http://www.cms.gov/medicare-coverage-database/staticpages/icd-9-code-lookup.aspxThis link will lead to an excel version of the latest codes: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.htmlGenitourinary Clinical CaseHPIA 60-year-old Hispanic male presents with the chief complaint of decreased urinary flow. The patient has been experiencing this over the past two years but for thepast two weeks the symptoms have increased significantly. The current symptoms are similar to what he experienced in the past. However for the past two weeks he hashad increased nocturia with decreased strength of urinary flow and slight terminal dysuria. Patient has had no treatment in the past. The nocturia has been verytroublesome over the past two weeks. Yesterday he had significant difficulty in starting his urine flow and this is interfering with daily activities. He needs to passurine four to five times every night. He has been urinating frequently and always needs to know if there are bathrooms around.Patient does not complain of any other radiating pain. He has had no treatment or diagnostic work up in the past but now the symptoms have been increasing inseverity. He believes he had a low-grade fever yesterday. The patient is not sure what is going on but thinks he may have cancer. He had significant obstructivesymptoms two days ago. Gradual worsening of symptoms has compelled him to seek medical help now.PMHPatient has not sought any medical care for this problem to date. He is being treated for hypertension and hypercholesterolemia. There is no known history of heartdisease but he was hospitalized five years ago as a suspected case of angina. He was diagnosed with chest wall syndrome for which he was treated and then released.There are no recent hospitalizations and no surgeries.ROSDenies any other positive review of systems. Denies abdominal pain nausea or vomiting. No blood in the stool. No gross hematuria.MEDICATIONSCardizem 240mg dailyZocor 20mg dailyPatient is compliant with the prescribed regimen and knows why he is being treated.ALLERGIES/REACTIONSNo known drug allergiesSOCIAL HISTORYPatient has a masters degree in engineering and his income is $65000.00 per year. Though the patient is educated he lacks an understanding of resources available tohim. Patient has no problems with finances. He has excellent access to healthcare but most often does not utilize the services to the extent that is expected. He hasan excellent health insurance coverage including a prescription plan.Patient is married and his spouse has excellent general health. He has two grown-up sons who live with their own families. They are 35 and 37 years old both alive andwell. Although the patient has a masters in engineering his knowledge of healthcare is inadequate. He believes that he is generally healthy.His perception of self-efficacy is adequate. He has very little stress. His support systems include his wife and friends from work who provide him with the requiredemotional support. There is no family dysfunction. The patient is high strung and an over achiever. He gets little from social support outside the home or work.Patient is originally from United States. He lives in a suburban setting. His resources include his wife and the people he works with. Though there are other resourcesavailable to him he is not sure what they are.HABITSSmoking: Non smokerAlcohol: Does not drinkSubstance use: Denies substance abuseDIET HABITSHis wife does most of the cooking. He believes that he gets adequate exercise eats healthy and maintains a regular checkup regime with his physician.WORK HABITSHe is an engineer and has always done the same work.FAMILY HISTORYHe has one sister and one brother. Both are alive and well. There is a remote history of heart disease among his aunts and uncles.PHYSICAL EXAMINTAIONVital Signs: BP right arm sitting 140/92; T: 99 po; P:80 and regular; R 18 non-labored; Wt: 200#; Ht: 71HEENT: WNLLymph Nodes: NoneLungs: ClearHeart: RRR with Grade II/VI systolic murmur heard best at the right sternal borderCarotids: No bruitsAbdomen: Android obesity non-tenderRectum: Stool light brown heme positive. Prostate enlarged boggy and tender to palpation.Genital/Pelvic: Circumcised no penial lesions masses or discharge.Testes are descended bilaterally no tenderness or massesExtremities Including Pulses: 2+ pulse throughout no edema in the lower legs.Neurologic: Not examinedLab Results/Radiological Studies/EKG InterpretationOnly place your full name in the top left corner of each page (no need to put the date time my name the name of the class etc. just your name)
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