Average Year Attorney Assignment Help: How to Answer This Question
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Original Question
Mr. Average is a 40 year old attorney who presents complaining of 3-4 weeks of rectal itching. He says that he has never had anything like this before, although he knows that he has some small hemorrhoids. He states that the itching seems to be worse at night. He has used some A and D ointment on the rectal skin without much benefit. He also tells you that he does suffer with constipation that began while he was in law school. It seems to be worse right before he has to go to court. With closer questioning, you discover that his diet is fairly low in fiber, and that his main beverage is coffee. He does not have any kind of routine exercise program. He does tell you that he does have “occasional” painless BRB on the toilet paper, but only if he is constipated. Mr. Average is married; he does not smoke or use illicit drugs. He and his wife have 3 children, all under the age of 8. On PE, he is a well developed male, in NAD. His vital signs are stable. His BMI is 31. His cardiac and lung exam are normal. His abdominal exam reveals normal bowels sounds, without organomegaly. The rectal exam reveals mucosa that appears a bit macerated. The skin of the anal opening is a bit friable. With Valsalva, you see 3 small bluish “lumps” that become visible. Internal and external sphincter tones are normal; stool is negative for blood. What would the following sections include? Assessment _______40% Medical Diagnoses with ICD-10 codes Differential Diagnoses with ICD-10 codes 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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