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Posted: May 11th, 2022
NR 511 Wk8 Course and Scientific Reflection
Please learn the connected information fastidiously and comply with the grading rubrics and directions.
Use the knowledge I’ve written under and construct on them as acceptable to write down the paper.
It is a reflection paper of my course work and medical rotations. Please do effectively to “think about” your self in a medical setting and elaborate on the factors I’ve written under.
Solely peer-reviewed articles revealed inside 5years within the U.S. solely must be used. Don’t use any web sites since they carry restricted info.
#Weak spot in medical setting: a whole lot of college students, wifi interruptions, restricted laptops for charting, half-day medical rotation
#Progress in medical rotation: documentation, knowledge assortment, analysis, differential analysis, remedy routine acceptable
#Two Nurse Practitioner core competencies
1. Know-how and Info Literacy Competencies (slides Eight-9)
2. Coverage Competencies (slides 9-10)
###Affected person Encounters
Affected person No 1
Identify: W.D. Age: 22-35years *Gender: Male. *Ethnicity: Caucasian *Observe up: 1week
*Kind of Encounter: Continual Sickness Administration
*Shopper Complexity: A number of/Continual/Uncontrolled Illness
*Kind of diagnostics: Laboratory *Ordering Diagnostics: Blood Check
*Therapeutics: Modify Medicines *Referrals: N/A
*Procedures: N/A
*Schooling: Conduct administration
Diet: keep away from spicy and fatty meals
Scale back caffeine consumption
Keep away from allergens
*Medicines: Antianxiety, Antidepressants
*Bodily Examination: Constitutional/important indicators
*Previous Medical Historical past
J30.9 – Allergic rhinitis, unspecified
F41.9 – Nervousness dysfunction, unspecified
G40 – Epilepsy and recurrent seizures
Okay21 – Gastro-esophageal reflux illness
E78.5 Hyperlipidemia unspecified
*Abilities and Procedures: N/A
*Notes
E&M Code 99395 preventive care, est. pt. Age 18-39
Mr. W.D. got here in in the present day with considerations of a 40Ibs weight reduction, decreased urge for food, and damaging conduct change, per his mom’s report. The affected person’s important indicators are inside limits, the affected person is stressed, unable to concentrate on the interview. The affected person has a psychiatrist following him. He’s on the next drugs
1. Seizure: Topomax pill 50mg. 1 tab PO 2times a day
Lamictal pill 100mg. 1tab PO 2times day by day
Depakote ER pill 24hours 500mg. 1 tab PO as soon as day by day
2. GERD: Omeprazole capsule Delayed-Launch 20mg. 1 Capsule 30minutes earlier than morning meals PO 1tab BID.
***Gaps in follow
caregiver competency about affected person care, treatment compliance
What may have been performed higher to handle presenting considerations
Affected person Quantity 2
Identify: B. Z. *Age: 36-55years *Gender: Feminine *Ethnicity : African-American
*Kind of Encounter: Acute / Episodic Care
*Shopper Complexity: Episodic (Acute Situation) *Observe-up:1 week *Kind of Website: Inside Medication
*Kind of Diagnostics: Laboratory, Radiology *Ordering Diagnostics: Ultrasound, Blood check, Chest Xray
*Referrals: Obstetrics and Gynecology
*Therapeutics: Train/exercise, Meditation, Ache administration, different selfcare administration
*Medicines: Analgesics Non-narcotics, Gastrointestinal brokers, Hypoglycemic brokers, Hypolipidemic brokers/Lipid brokers, Respiratory brokers, Nutritional vitamins/herbs
*Therapeutics: Train/Exercise, Meditation, Different self-care administration, ache administration
*Procedures: blood draw/venous
*Schooling: Weightloss administration
Remedy routine
Diet
Physique mechanics
Bodily workouts
Keep away from allergens and respiratory irritants,
*Bodily Examination: constitutional/important indicators, gastrointestinal, genitourinary, gynaecology, HEENT, musculoskeletal, neurological techniques, and ache evaluation
*Schooling
Weightloss administration
Remedy routine
Diet
Physique mechanics
Bodily workouts
Keep away from allergens and respiratory irritants
*Previous Medical Historical past
45 – Bronchial asthma
Okay21 – Gastro-esophageal reflux illness
E78.5 – Hyperlipidemia, unspecified
E66.zero – Weight problems attributable to extra energy
E55 – Vitamin D deficiency
*Abilities and Procedures: Blood draw venous
*Notes
E/M Code 99215 est. pt. degree 5
Ms. B.Z got here with considerations of decrease and higher again ache and decrease belly ache. She denies heavy lifting, pressure on the again, and improper physique mechanics. The affected person experiences a ache degree of seven/10 unrelieved with Tylenol and relaxation. The ache has interrupted her work schedule. The affected person has a historical past of prediabetes, hyperlipidemia, GERD, bronchial asthma, and Vitamin D deficiency.
Medicines
Phentermine HCL 37.5mg tablets. 1tab PO as soon as day by day x 90days
Metformin HCL 500mg tablets. 1tab PO as soon as day by day x 90days
Ergocalciferol 1.25mg capsule. 1cap PO weekly x 90days
ProAir HFA 108 (90base) mcg ACT Aerosol resolution. 1-2puffs inhalation PRN This autumn-Q6hrs
Omeprazole 20mg capsule Delayed-Launch capsule. 1cap PO twice day by day x 90days
***Gaps in follow
treatment non-compliance, unsuccessful weightloss efforts BMI (30)
What may have been performed concerning the gaps in follow?
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