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Dоcumenting the pаtient encоunter (PLO 5) HPI: Mr. Cоnnolly is а 50 y/o M pаtient with a past medical history of hypertension, hepatitis C (s/p treatment), lumbar strain, and depression who presents with complaints of “having difficulty sleeping for the last 2 days.”. Pt elaborates by stating that he just can’t seem to fall sleep, noting that if he falls asleep, he doesn’t stay asleep long. He feels agitated, shaky, and restless. He denies excessive caffeine use or drug use such as stimulants. Pt reports that he has not experienced anything like this before. He notes that this seems to be worsening since onset and is constant. Pt states that the symptoms seem worse at night when attempting to sit for a prolonged period. He is unsure of any alleviating factors. Associated symptoms include nausea without vomiting, as well as sensation of both of his hands feeling shaky and tremulous today. He denies tremors elsewhere or history of this. No reported gait or movement problems. The tremors have been for the last day, along with a sensation of racing heart, and increased anxiety. Patient feels sweaty at times with new loss of appetite over the last 1-2 days. Furthermore, he denies chest pain, SOB, headache, changes in vision, or changes in bowel or bladder function. Of note, pt reports that recently hurt his back and has been out of work for about 3 months. Pt recently ran out of all his medications 2 days due to personal financial issues at the moment. He did not have the money to refill them at that time, as all were due. Pt had previously been taking all of his medications daily, including sertraline, HCTZ, and diazepam daily for the last 3 months. Pt admits that he was taking more Valium than prescribed prior to running out of his meds, but does not specify how much. Medications: Zoloft (sertraline) 25 mg daily for depression, HCTZ 25 mg daily for hypertension, and Valium (diazepam) 5 mg PO 1 tablet every 12 hours PRN back spasms. Allergies: NKDA Past Medical History: Chronic conditions: Hypertension (diagnosed 15 years ago) Hepatitis C (diagnosed 15 years ago, treated to cure with Ledipasvir and sofosbuvir (Harvoni) 2 years ago) Depression (diagnosed 2 years ago and has been seeing a psychiatrist since) Lumbar back strain from a work-related injury lifting heavy boxes 3 months ago Pt denies any other known health diagnoses Hospitalizations: For pneumonia treatment once 10 years ago (only stayed a few days in the hospital) Surgeries: None Immunizations: Pt believes he is up to date on his required vaccines/immunizations. Family History: Father: deceased, age 66 years old. Incarcerated for many years and does not like to talk about his father, but notes he was an alcoholic. Mother: alive, 75 years old. Known hx of asthma and depression Sister: alive, age 48, Known hx of anxiety, otherwise healthy Social History: Tobacco/Vape: 1 pack of cigarettes per week for the last 25 years. Caffeine Use: Occasional cup of coffee in the morning, no change in caffeine use recently Alcohol: Pt does not drink alcohol due to a history of hepatitis C in the past. Pt reports he is scared to drink because he was told not to after being diagnosed with hepatitis C many years ago. Illicit drugs: Denies Marital/Sexual: Pt is single, never married. He reports being sexually active with a new partner over the last year. States he uses condoms when sexually active. Living situation: Lives in an apartment near El Cahon Job: Previously worked in a factory recently laid off due to inability to work; was working shift work equating to long days. But now, pt has been unable to work since due to his back injury and hasn’t been paid in over a month. Hobbies/Exercise: Fixing his antique sailboat. Likes to ride his motorcycle (wears a helmet). Pt does not exercise regularly and has been unable to do much activity since the back problem started. Diet: Normal diet Religion: Buddhist Sleep: Normally averages 7 hours of sleep per night normally, but significantly less recently. ROS Constitutional: See HPI. Denies fever, chills, night sweats, unintentional weight loss or weight gain recently. Skin: Denies hair loss, nail pitting, rashes, lesions, or skin discoloration. HEENT: Denies rhinitis, sore throat, congestion, ear pain or discharge, eye pain or change in vision, headache. Denies hearing changes, tinnitus, or nasal discharge. No lymph node swelling reported. CV/PV: Pt does admit to feeling like his heart is “racing” today. Denies chest pain or tightness, swelling or edema of lower extremities. No syncope or pre-syncope reported. Pulmonary: Denies SOB, coughing, wheezing, hemoptysis, stridor, dyspnea, orthopnea, or pain with inspiration. GI: See HPI. Denies constipation, diarrhea, abdominal pain or distention, or vomiting. GU: Denies dysuria, increased (or decreased) urinary frequency, urgency, or hematuria. Denies urinary incontinence. MSK: See HPI. Denies recent trauma within the last week. He also denies muscle weakness, joint swelling or joint pain, difficulty moving any joints, arthralgias or myalgias. No leg shaking at night reported. Neuro: See HPI. Denies headaches, dizziness or lightheadedness, dysarthria, slurred speech, or weakness. Denies any known history of seizures or recent seizure-like activity. Psych: See HPI. Denies confusion, racing thoughts, suicidal ideation, homicidal ideation or hallucinations. Endocrine: Denies heat or cold intolerance, polyuria, polydipsia, or polyphagia. Heme/Lymph: Denies any recent or remote easy bruising or bleeding. Documenting the patient encounter: (A.) Based on the provided full patient history, identify your top suspected diagnosis. In addition to your top suspected diagnosis, please identify and list ten (10) critical pieces of information to document in this patient’s chart for this case to support your diagnosis and/or rule out any other concerning diagnoses. [PLO 5] (B.) Then, provide a brief rationale for each critical documentation item provided as to why you feel it is important and relevant to document in this case.
Which is the first prоfessiоnаl оrgаnizаtion that included PAs in their forensic accreditation standards?
Dоcumenting the pаtient encоunter (PLO 5) HPI: Mr. Cоnnolly is а 40 y/o M pаtient with a past medical history of hypertension, hyperlipidemia, and depression who presents with complaints of “restlessness and agitation for the last 24 hours.”. Pt elaborates that this is a sense of “shakiness”, and feeling “unsettled”. Pt reports that he has not experienced anything like this before. He notes that this seems to be worsening since onset and is constant, having caused him difficulty sleeping last night as result. Pt states that the symptoms seem worse when attempting to sit from a prolonged period. He is unsure of any alleviating factors. Both of his hands feel shaky/tremulous today, which caused him concern to seek care. He denies tremors elsewhere. Associated symptoms include decreased appetite, sweating despite no physical exertion, nausea without vomiting, sensation of heart racing today, difficulty going to sleep as well as staying asleep last night, and feeling anxious and like he can’t sit still today. He denies prior service as a veteran or prior history of recent significant trauma or injury. He also denies CP, SOB, HA, changes in vision, changes in bowel or bladder function, or difficulty walking. Of note, pt reports that approximately one month ago, one of his best friends committed suicide and since that time he had been drinking alcohol heavily “to forget about it”. That continued until about 24-36 hours ago, when his psychiatrist suggested that he cut back on his drinking. He decided to stop entirely, noting he did not drink much prior to that time and figured it would be best to go “cold turkey”. He admits to drinking at least 1-2 pints of hard liquor per day during that time. He denies other drug use. Medications: Zoloft 25mg PO daily; HCTZ 25mg PO daily; Atorvastatin 20mg PO daily Allergies: NKDA Past Medical History: Chronic conditions: Hypertension (diagnosed 10 years ago) Hyperlipidemia (diagnosed 10 years ago) Depression (diagnosed 1 year ago and has been seeing a psychiatrist since) Pt denies any other known mental health diagnoses Surgeries: None Immunizations: Pt believes he is up to date on his required vaccines/immunizations. Family History: Father: alive, 66 years old. Incarcerated and does not like to talk about his father, but notes he was an alcoholic. Mother: alive, 65 years old. Known hx of asthma and depression Sister: alive, age 38, Known hx of anxiety, otherwise healthy Brother: alive, age 36, Known hx of traumatic brain injury after being hit by a car at age 10 Social History: Tobacco/Vape: 1 pack of cigarettes per week for the last 20 years. Caffeine Use: Occasional cup of coffee in the morning, no change in caffeine use recently Alcohol: See HPI. Pt reports heavy daily alcohol use until recently over the last 30 days. Reports having 1-2 vodka drinks per night only on the weekend, prior to that time. Illicit drugs: Denies Marital/Sexual: Pt is single. He reports being sexually active with his long-term girlfriend over the last few years. States he uses condoms when sexually active. Living situation: Lives alone in El Cajon currently Job: Works as a machinist in a local factory doing shift work 11a-11p, noting that he missed a few days of work recently due to a hangover. Pt states the job is demanding and stressful at times. Reports he was almost fired a few days ago due to showing up late. Hobbies/Exercise: Fixing his antique car. Does not exercise regularly. Diet: Normal diet Religion: Agnostic Sleep: Averages 6-7 hours of sleep per night normally, less recently. ROS: Constitutional: See HPI. Denies fever, chills, night sweats, unintentional weight loss or weight gain recently. Skin: Denies hair loss, nail pitting, rashes, lesions, or skin discoloration. HEENT: Denies rhinitis, sore throat, congestion, ear pain or discharge, eye pain or change in vision, headache. Denies hearing changes, tinnitus, or nasal discharge. No lymph node swelling reported. CV/PV: Pt does admit to feeling like his heart is “racing” today. Denies chest pain or tightness, swelling or edema of lower extremities. No syncope or pre-syncope reported. Pulmonary: Denies SOB, coughing, wheezing, hemoptysis, stridor, dyspnea, orthopnea, or pain with inspiration. GI: See HPI. Denies constipation, diarrhea, abdominal pain or distention, or vomiting. GU: Denies dysuria, increased (or decreased) urinary frequency, urgency, or hematuria. Denies urinary incontinence. MSK: Denies trauma, muscle weakness, joint swelling or joint pain, difficulty moving any joints, arthralgias or myalgias. Neuro: See HPI. Denies headache, dizziness or lightheadedness, dysarthria, slurred speech, or weakness. Denies any known history of seizures. Psych: See HPI. Denies confusion, racing thoughts, suicidal ideation, homicidal ideation or hallucinations. Endocrine: Denies heat or cold intolerance, polyuria, polydipsia, or polyphagia. Heme/Lymph: Denies any recent or remote easy bruising or bleeding. Supplemental Screening Completed: CAGE Questionnaire- Have you ever felt you should CUT down on your drinking? “Yes” Have people Annoyed you by criticizing your drinking? “No” Have you ever felt bad or Guilty about your drinking? “No” Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)? “Yes” AUDIT-C Questionnaire: How often did you have a drink containing alcohol in the past year? “Only 1-2 days per week, until the last month when I was having a drink 5+ days per week” How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? “Not many until recently, when I was having 5+ drinks daily over the last month.” How often did you have six or more drinks on one occasion in the past year? “Nearly daily since the death of my friend, until I cut back.” Documenting the patient encounter: Based on the provided full patient history, identify your top suspected diagnosis. In addition to your top suspected diagnosis, please identify and list ten (10) critical pieces of information to document in this patient’s chart for this case to support your diagnosis and/or rule out any other concerning diagnoses. [PLO 5] Then, provide a brief rationale for each critical documentation item provided as to why you feel it is important and relevant to document in this case.