Awake alert and oriented cooperative 28 years old seated on the exam table

Awake alert and oriented cooperative 28 years old

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Awake, alert and oriented, cooperative, 28 years old, seated on the exam table concern about her infection Skin Measured wound: 2 cm x 1.5 cm, 2.5 mm deep Wound in the right plantar, Neck is getting darker and acne HEENT Click or tap here to enter text. Click or tap here to enter text. Respiratory Click or tap here to enter text. Click or tap here to enter text. Neuro Click or tap here to enter text. Click or tap here to enter text. Cardiovascular Click or tap here to enter text. Click or tap here to enter text. Musculoskeletal Click or tap here to enter text. Click or tap here to enter text. Gastrointestinal Click or tap here to enter text. Click or tap here to enter text. Genitourinary Patient stated she get bad periods Click or tap here to enter text. Psychiatric Click or tap here to enter text. Tina stated feelind depressed after her dad passed away and now she is concern about her foot.
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Problem List 1. Acute pain of the right foot 6 Hypertension 11 Click or tap here to enter text. 2 infection of the skin and subcutatneous tissue of the right foot 7 Obesity 12 Click or tap here to enter text. 3 uncontrolled type 2 diabetes mellitus 8 Polyscystic ovarian syndrome 13 Click or tap here to enter text. 4 Asthma 9 Oligomenorrhea 14 Click or tap here to enter text. 5 Dysmenorrhea 10 Menorrohagia 15 Click or tap here to enter text. Diagnosis ICD-10 Code Pertinent Findings Infection of the R Foot L08.9, S91 A drainage wound that measure 2 cm x 1.5 cm, 2.5mm deep Acute pain M25.571 Pain of 7/10 Uncontrolled type 2 diabetes E11.5 Blood sugar of 238 Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Medications: List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent. Drug Dosage Length of Treatment Rationale/Citation Clindamycin 300 mg 7 days Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. P: Plan Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention. A: Assessment Medical Diagnoses. Provide 3 differential diagnoses which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis.
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  • Fall '15
  • Tina, Medical diagnosis

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