Folsum Presents Complaining Question & Answer Guide (With Explanation)
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Original Question
Mr. Folsum presents complaining of “vision changes” and painful lower back. Mr. Folsum says that he has had two episodes of blurred vision in his right eye. Both occurred last week while he was sitting at his desk paying bills. He said that he had a little tingling in the left upper arm, but no weakness. The episodes lasted no more than 3 minutes. He was able to move all other extremities during the episode and he had no difficulty with speech. Both times he said that he got up and took a second dose of aspirin. He had no symptoms such as palpitations, shortness of breath or chest pain during the episodes. His second problem is that he has lower back pain with walking. He denies injury and he says that he has absolutely no symptoms at night or when just sitting. He states that he cannot go to the mall with his wife because he has to stop and rest every 5 minutes because his lower back really starts giving him fits after he has walked for a while. He says that these symptoms have been present for about 6 months, but worse over the last 2 months. He denies pain in his legs at night, and says that he is bothered “a little bit” with upper thigh and calf pain when he walks, but nothing like the pain he experiences in his lower back. PMH is significant for HTN, Hyperlipidemia, Cerebralvascular Disease; Coronary Artery Disease; MI x 2 [1980; 1990]; GERD. Previous Surgeries: Bilateral Carotid Endarterectomies [2001]; Coronary Angioplasty x 2 [2000]; Malignant Melanoma removed beneath right scapula [1995]. Allergies: Coumadin [rash with small area of skin sloughing when used after angioplasty 2000]; Penicillin Medications: Toprol XL 200 mg @ hs; Prinivil 40 mg q a.m; Demadex 20 mg q a.m.; Zocor 40 mg. q evening; Protonix 40 mg q a.m.; ASA 325 mg q d Social Hx: he no longer smokes or drinks [quit in 1995]; prior to that he drank 1/5 of Irish whiskey per week and he smoked 1 ppd of cigarettes and had for 30 years; he is retired; she is still active in his church; he drives and mows his lawn; he does all of the housework and cooking because his wife of 45 years still works 4 days per week. On PE, Mr. Folsum is pleasant. He is a 70 year old white man in NAD. VS: 98-60-16-120/68 70″ 180# He is alert and oriented to person place and time. Eye exam reveals PERRLA, no AV nicking, no hemorrhages in the eye grounds. Neck is supple with bilateral carotid bruits. Heart is regular in rate and rhythm. He has a 2/6 holosytolic murmur @ the apex. Carotids, brachials, radials, and femoral pulses are all palpable 2+ bilaterally. When examining his back he points to his buttocks as the actual site of his discomfort with exercise. Back exam is unremarkable; SLR is negative bilaterally. Muscle strength is normal 5/5 bilaterally. He has no pulses below the femorals that are palpable. His feet are warm and without lesions, dependant rubor is present. Hair growth is sparse below the groin bilaterally. Nails are smooth and flat. DTRs 2+/2+ upper and lower extremities. His EKG is in a normal rhythm [sinus bradycardia]; recent echocardiogram by his cardiologist was stable and showed no acute problem with his valves or wall motion. His ejection fraction was estimated to be 40%. Can you answer the following questions? Assessment _______40% Medical Diagnoses with ICD-10 codes Differential Diagnoses with ICD-10 codes Rule out #1 Rule out #2 Rule out #3 Rule out #4 Nursing Diagnosis/Health Maintenance or Social issue: Initial Treatment Plan ________20% Diagnostics/Laboratories ________20% Rxs ________20% Nursing Interventions / Education ______ TOTAL (100%)
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