How to Answer Bernice Year Retired Questions (Complete Guide)
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Original Question
Bernice is a 66-year-old retired teacher who you having been seeing for vascular dementia. She is in for a recheck today. You saw her 6 weeks ago, and started her on Aricept 5 mg at HS for her dementia. The patient and her daughter state that she is tolerating the medicine without untoward effects and thinks it is helping her already. The daughter says that her mom is really having trouble incontinence. She says she gets the urge to go, but often cannot make it to the bathroom without wetting herself. She has no issues at night, as she does not need to get up at night to go to the bathroom. The patient denies hematuria, dysuria, nocturia or flank pain. PMH—Vascular Dementia; Depression; Seasonal Allergies; Urinary Incontinence; Osteoporosis; Dyslipidemia; GERD; Stoke [5 months ago; residual memory impairment] Allergies—none to medications; no alcohol or tobacco Medications—Crestor 20 mg daily; ASA 325 mg daily; Plavix 75 mg daily; Prolia 60 mg SC every 6 months; Pepcid 40 mg daily prn; Tylenol 650 mg [1] daily prn pain; Vitamin D3 5000 IU daily; Aricept 5 mg daily at HS [started 6 weeks ago,]; Benadryl 25 mg daily prn allergies Social Data—retired teacher; has a master’s degree in education; has been living with daughter [who is an RN] and son-in-law for the past year On exam, she is a young appearing white woman in no acute distress. VS: 97-76-16 130/70 62 inches tall 110 pounds She is well groomed; skin hair and nails are normal EENT—slight injection of the conjunctiva; turbinates are swollen and boggy, but no exudates; throat is clear; no swollen lymph nodes to neck, maxillary or submental regions Lungs/Heart—clear to auscultation; no murmur, gallop or rubs; heart is regular in rate and rhythm; no edema MSK—there is dorsal kyphosis; gait is steady but she is using her cane GU—non distended bladder on exam; PVR is less than 60 cc; dip urine in the office is normal—rare WBC, rare bacteria, no RBCs, no nitrites; color yellow and clear Neuro—she is oriented to person and place; her mental status is assessed with the Folstein Mental Status Exam and she scores 25/30 [27 and higher is considered normal]; she seems to get confused on details regarding her medical history, but she can tell you everything that she and her daughter did yesterday—including what she had to eat for lunch yesterday [at the restaurant at North Park Mall]. The daughter tells you that this is typical for her mum—sometimes her memory seems decent, then the next day she will be mixed up all day long. Medical Diagnoses and Rule Outs: List all medical diagnoses and ICD-10 codes; then list a minimum of 4 rule out diagnoses with ICD-10 codes. This section also requires one Health Maintenance/Nursing/Social Issue or Diagnoses with ICD-10 code. Diagnostics/Labs: Cite needed diagnostics and labs needed to begin your treatment plan. This section is worth 20 points. 1-10 points is deducted for critical omissions. Treatment: This section is your beginning treatment plan. Note referrals and prescriptions. If meds given–OTC or prescription, you must note dose, route, frequency and duration. Education: It should include appropriate education relevant to the patient’s working diagnoses and other major medical/health maintenance issues that you identify on this patient.
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