What is the structure of a subjective data set for a new patient’s annual wellness exam?

  

see below
Identify a friend, peer, or family member you can interview to
collect. information to construct a complete and comprehensive
subjective data set consistent with documentation requirements for
a new patient scheduled for an annual wellness exam.

Conduct an interview.
Document your findings in a Word file. Structure the subjective data

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set in the format provided in your lecture materials.
Submit the Word file containing your subjective data set into

Canvas

Estimated time to complete: 1 hour

Kyle P

Chief Complaint: New Patient

Subjective:

CC: new patient wellness check

HPI: 33 years old male, being seen for comprehensive new patient examination. Denies current illness.

Patient subjectively reports increased urination and thirst. Reports nausea daily. Patient also reports some

mild visual changes when reading for longer period. Did not disclose the onset or duration of problem. Pt

reports ongoing diarrhea tries to control with use of OTC medication, pt reports swelling in lower

bilateral legs, ashy tone to both legs. Reports having ongoing neuropathy in both legs.

PMH

Diagnoses: HTN, DM 1, ED, Depression, Anxiety, IBS, chronic pain,

Hospitalizations: Multiple admits related to poorly managed DM unknown amount states around

10 or more

Surgeries: NA

DME:

Allergies:

Rx: NDKA

Food/Bev:NKA

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Environment: NKA

Medications/Therapies:

Rx: Insulin/ Humalog (sliding scale) ( Treat DM) AC/HS, gabapentin 300mg PO BID

( Neuropathy), Sildenafil 100mg PO PRN (For ED)

Supplements:

Alt. Tx. Modalities: Pepto Bismol, Tums

Social:

As it R/T CC:

Family and Home: Lives in a 2-bedroom apartment where he has non established split custody of

his 8-year-old son.

Edu/literacy: High school diploma, special training r/t job

Occupation/hazards/stressors: Auto Mechanic for 40 hours a week

Relationships: monogamous one partner

Sex/STD risk: no screens in past for STD, currently in one partner relationship

Drugs/Etoh/Tobacc/Caff: reports using THC for IBS and chronic pain uses daily particular at HS.

Reports vaping nicotine. Does not typically consume caffeine products other than 2 cups a coffee daily. Pt

reports only drinking alcohol socially. Drinks maybe once or twice a month 1-2 cans beer.

Cult/Spiritual: Denies spiritual

$$ circumstances: pt reports not having medical insurance and reports that he makes too much to

qualify for Medicaid, pt also reported that he was told by employer due to his medical history he could

not obtain their medical insurance.

FMH:

Maternal: living- reports that she is addict with ongoing mental health issues

Paternal: did not disclose

Children: Son(8)- type one diabetes

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Siblings: did not disclose

Wellness:

General:

Vaccines/PPD: reports only receiving childhood vaccines, denies any boosters

Activity level: denies daily exercising. Reports that work exhaust him, reports always feeling

tired and reports poor sleep patterns

Diet: low carb/ diabetic friendly

Dental/Vision: states that it has been over 3 years since last exam for eye and dental. Trouble

reading for long periods burry vision

Screenings: reports labs only when admitted for DM,

BMI: 56, 130lb

General: well groomed, 33-year-old white male. Appears slightly anxious

VS: 156/112, 112, 18, 98%, 56, 130lb Chronic pain 6

Skin: edema, ashy tone to bilateral legs

HEENT: reports glasses when reading

Neck: wnl

CV: HTN, tachycardia

Lungs: diminished

GI: ongoing diarrhea, Abdomen: nodules from constant insulin injection, soft non distended, bowel

sounds in all 4 quad.

GU: increased urination, increased thirst

PV: edema bilateral lower extremities, ashy tone to legs +2 cap refill to legs, neuropathy to legs ongoing

pain

Musculoskeletal: wnl

Neuro exam: anxiety, depression

Diagnostic Tests:

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Reproductive: ED for past 2/3 years

Immune/Rheum:

ASSESSMENT:

Diagnoses: Patient in for new patient wellness appointment. DM 1 poorly managed only using Humalog

short acting, not receiving long acting, HTN poorly managed not receiving treatment, ED- poorly

managed reports medication is only partially effective, chronic pain- controlled with medication

gabapentin, IBS- poorly managed only treating with OTC.

PLAN:

For each Dx above: If N/A, include why/why not

Diagnostics:

Therapeutics:

Education:

Consult:

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http://www.tcpdf.org Identify a friend, peer, or family member you can interview to collect submit comprehensive subjective and objective data sets, as though they were a new patient in your office for an annual wellness visit or establishing as a new patient to the practice.Conduct an interview and physical exam Structure the subjective and objective data sets in the format provided in your lecture materials.

Introduction:
Comprehensive subjective data set documentation is crucial for a new patient scheduled for an annual wellness exam. The subjective data helps healthcare providers understand the patient’s health status, medical history, and current concerns. This information is necessary for developing a comprehensive care plan and conducting a physical examination. In this study, we present the subjective data set for Kyle P, a 33-year-old male patient, who has come for a new patient wellness check.

Description:
Kyle P is a new patient who presents with mild visual changes when reading for a longer period. He also reports increased urination and thirst, nausea, diarrhea, swelling in lower bilateral legs, and ongoing neuropathy in both legs. He has a medical history of hypertension, Type 1 diabetes, erectile dysfunction, depression, anxiety, irritable bowel syndrome (IBS), and chronic pain, with multiple hospitalizations related to poorly managed diabetes. Kyle P is an auto mechanic who works 40 hours a week and has non-established split custody of his 8-year-old son. He uses THC for IBS and chronic pain and vapes nicotine. Kyle P reports poor sleep patterns, poor diet, low exercising activity, and reports not having a medical insurance coverage. In this data set, we have structured Kyle P’s subjective data by following the format outlined in the lecture materials.

Objectives:
– To identify and interview a friend, peer, or family member to collect information to construct a comprehensive subjective data set for a new patient scheduled for an annual wellness exam.
– To structure the subjective data set in the format provided in lecture materials.
– To document findings from the interview in a Word file.

Learning Outcomes:
By the end of the exercise, students will be able to:
– Conduct an interview with a friend, peer, or family member to collect information for a subjective data set.
– Organize and structure the subjective data set in the format provided in lecture materials.
– Identify and document relevant patient information, including chief complaint, medical history, medications/therapies, social factors, and wellness status.
– Understand the importance of thorough subjective data collection for new patient wellness exams.

Solution 1: Comprehensive Treatment Plan for Kyle P

Objective: To create a comprehensive treatment plan for Kyle P to manage his multiple health conditions and improve his overall quality of life.

1. Diabetes Management: Kyle P needs to consistently monitor his blood glucose levels and adhere to a diabetic-friendly diet, including low-carb and low-sugar options. Insulin should be administered on a sliding scale, and Humalog should be taken before meals and at bedtime.

2. Neuropathy: Gabapentin 300mg PO BID should be continued to manage neuropathy symptoms.

3. Erectile Dysfunction: Sildenafil 100mg PO PRN should be taken as needed to manage ED.

4. Gastrointestinal Issues: Kyle P should try alternative treatment modalities such as diet modification or seeking specialist advice, as Pepto Bismol and Tums are no longer effective.

5. Depression and Anxiety: Kyle P should seek professional help from a therapist and take appropriate medications to manage depression and anxiety symptoms, such as SSRIs.

6. Chronic Pain: Kyle P should seek specialist advice to manage chronic pain with appropriate pain medications.

7. Hospitalizations: Kyle P should be advised to manage his DM effectively to avoid further hospitalizations.

8. Visual Changes: Kyle P should schedule an appointment with an optometrist for a thorough eye examination for his mild visual changes.

Solution 2: Financial Assistance for Healthcare Coverage

Objective: To assist Kyle P in obtaining medical coverage despite his medical history and current financial situation.

1. Research insurance options: Research and provide Kyle P with a list of possible insurance options available in his state, such as state or federal programs, or programs offered by his employer.

2. Explore Medicaid eligibility: Check Kyle P’s eligibility for Medicaid and help him understand the application process to determine if he can qualify.

3. Provide information on low-cost clinics: Provide information on free or low-cost clinics in his area that can provide medical care at reduced rates for uninsured patients.

4. Research charity organizations: Research and provide information on charity organizations that offer medical assistance for patients with financial hardships.

5. Assist with the application process: Assist Kyle P with the application process for Medicaid or other health insurance programs to ensure that all necessary documentation is submitted, and follow up with the agency until Kyle P obtains medical coverage.

Suggested Resources/Books:
1. “Bates’ Guide to Physical Examination and History Taking” by Lynn S. Bickley MD
2. “Clinical Case Studies for the Family Nurse Practitioner” by Leslie Neal-Boylan PhD CRRN APRN FAANP
3. “Primary Care: A Collaborative Practice” by Terry Mahan Buttaro PhD ANP-BC GNP-BC FAANP

Similar Asked Questions:
1. What should be included in a comprehensive subjective data set for a new patient wellness check?
2. How does a patient’s medical history impact their annual wellness exam?
3. What are some common symptoms of poorly managed diabetes?
4. What are some potential causes of neuropathy in both legs?
5. How does a lack of medical insurance affect a patient’s healthcare experience?

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