Sandy Year Patient Assignment Help: How to Answer This Question

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Original Question

1. Sandy is a 64-year-old patient with a 10-year history of recurrent sinusitis. She presents to your primary care clinic today complaining of “head congestion.” She also reports that she had a “cold” last week with symptoms of cough and “runny nose.” Two days ago, she developed a headache that was “worse” when bending over but improved with Tylenol. She describes the headache as a “3 out of 10” and says it is primarily a “frontal headache.” She also reports that her nasal congestion has become worse. She has been blowing her nose even more, and the discharge from her nose has become thicker, with a yellow-green color. She has been taking pseudoephedrine for the past 48 hours with little relief of her nasal congestion. She denies tooth pain or pain on chewing. She has no past history of seasonal allergies, although she was treated for sinusitis 6 months ago in your clinic as well as approximately one year ago. The remainder of her medical history is essentially negative. Her temperature taken at the clinic is 99.6°F. On physical examination, she has tenderness to palpation in the frontal area and no maxillary tenderness, and nasal mucosa is erythematous as is her pharynx. Her submaxillary nodes are enlarged bilaterally, but there is no cervical lymphadenopathy. Her lungs are clear to auscultation. Her heart has a regular rate and rhythm and is negative for murmurs, gallops, and rubs. Her vital signs are: Blood pressure:128/88; Pulse: 78 and regular; Respiratory rate: 20 p/min, non-labored. In SOAP format as advised below? SUBJECTIVE: Questions you will ask HPI PMHx FHx SHx Medications ROS OBJECTIVE: Vitals with BMI Constitutional HEENT Cardiac Pulmo GI Musculoskeletal Skin GU – if relevant Always provide a very detailed physical exam, or description of what you want to elicit on your physical exam on the organ system involved in your chief complaint ASSESSMENT: Working Diagnosis – provide ICD 10 codes – provide rationales or pertinent positives and negatives that made you consider the diagnosis Differential # 1 – diagnosis you cannot miss. – rationale why it can’t be missed – provide ICD 10 code Differential # 2 – what else could it be? – rationale why you ruled it out -provide ICD 10 Code PLAN Diagnostics Pharmacological Plan – indicate dosage and regimen, if not indicated state accordingly Health Education Plan Referral Plan – if not indicated, state accordingly Follow-up plan – indicate when patient needs to follow-up and what symptoms to watch out for Health promotion plan – age-specific health promotion recommendations not related to the case per USPTF National Standards of Care/ Short Narrative for working diagnosis

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