A 72-year-old male is seen in the office with a complaint of difficulty urinating and starting urina

Question
Answered step-by-step
Asked by PresidentJackal1616

A 72-year-old male is seen in the office with a complaint of difficulty urinating and starting urinary stream. The patient states he has had problems starting urinary stream for about 10 years, but over the past 2 months, he has noticed that not only is this difficult, but at times, it is very difficult to empty his bladder. He reluctantly states that he has had a few episodes of incontinence.

Answering in below format 

 

 

SOAP FORMAT

 

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

 

REFERENCES

SCIENCE
HEALTH SCIENCE
NURSING
NURS 663LA

 

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."