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.

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.

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 official system 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.aspx

•This link will lead to an excel version of the latest codes: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html

Genitourinary Clinical Case

HPI

A 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 the past 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 has had increased nocturia, with decreased strength of urinary flow and slight terminal dysuria. Patient has had no treatment in the past. The nocturia has been very troublesome 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 pass urine 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 in severity. 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 obstructive symptoms two days ago. Gradual worsening of symptoms has compelled him to seek medical help now.

PMH

Patient 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 heart disease, 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.

ROS

Denies any other positive review of systems. Denies abdominal pain, nausea or vomiting. No blood in the stool. No gross hematuria.

MEDICATIONS

Cardizem 240mg daily

Zocor 20mg daily

Patient is compliant with the prescribed regimen and knows why he is being treated.

ALLERGIES/REACTIONS

Explanation & Answer

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