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Posted: April 13th, 2023
Mr. Fowler is 70 yrs old who is sent to the ED derby his primary care physicians for further evaluation .He has orothostatic hypotension, history of creatinine 3.2 with microalbuminuria,nausea and dry heaving ×24hours,reduced urine output, reduced urine output, reduced appetite x3,nausea and vomiting x 3to 4 days ,tachycardia, lightheadedness when stands up quickly, new NSAID use,fatigue, dry mucous membrane, mild tenderness in epigastric and periumbilical region .
Below is the template you are to follow when developing your management plan. Also, always be sure to complete the EMR on the case. Use this template with each case. It is not a SOAP format as that is not required. Points will be deducted for not utilizing the template.
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THIS SECTION IS 30 POINTS!!! Follow the bullet points below. Copy and answer each bullet point on a word document and cut and paste your responses to the management section!
Primary Diagnosis and ICD-10 code: Also include any procedural codes.
3-5 Differential Diagnoses- Why? What made you select each one as a DDX? How did you rule out? This would be a good area to include references.
Additional laboratory and diagnostic tests: It may be necessary to establish or evaluate a condition. Some tests, such as MRI, may require prior authorization from the patient’s insurance carrier.
Consults: referrals to specialists, therapists (physical, occupational), counselors, or other professionals. If you are sending it to the hospital, what orders would you write for a direct admit?
Therapeutic modalities: pharmacological and nonpharmacological management.
Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening.
Patient education: Explanations and advice given to patient and family members.
Disposition/follow-up instructions: when the patient is to return sooner, and when to go to another facility such as the emergency department, urgent care center, specialist, or therapist.
References (minimum of 3, timely, that prove this plan follows the current standard of care).
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