Peer Response: Unit 13, Due Sunday by 11:59 pm CT
Instructions:
Construct a response to at least 2 of your peers ideally one who determined the same list of diagnoses that you did and one who did not.
Include in your response discussion identification of the subjective and/or objective data OR absence of same that supports your agreement or disagreement with your course colleague.
Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.
Please be sure to validate your opinions and ideas with in-text citations and corresponding references in APA format.
Please review the rubric to ensure that your response meets the criteria.
Estimated time to complete: 2 hours
PLEASE UPDATED REFERNCES FOR EACH PEER POST I WILL PROVIDE THEM AND INSTRUCTIONS PROVIDED I WILL PROVIDE SOAP NOTE WE ARE REPLYING ABOUT
PEER#1 AND PEER#2
Collapse SubdiscussionBriana Campbell
Briana Campbell
TuesdayAug 10 at 8:47pm
Unit 13 Discussion – Data Set Analysis
Assessment (A):
Zoster without complications (B02.9)
Subjective: Complaints of rash to the right shoulder; “stabbing” pain to the shoulder area; burning sensation and “itchy”; aggravated with touch and when she gets hot; fever of 100.8; generalized fatigue; denies any prior episode of rash, trauma, injury, illness exposure, or recent exposure to irritants; history of chicken pox; denies receiving shingles vaccine
Objective: Temp 100.6; Unilateral erythematous, maculopapular rash with small areas with developing vesicles to right, posterior, upper shoulder with a dermatomal distribution; The rash is 4cm length by 2cm width
Unspecified hearing loss, right ear (H91.91)
Subjective: Reports hard of hearing to right ear
Objective: Mild hearing deficit to whisper test on right ear
Stress incontinence (N39.3)
Subjective: Reports stress incontinence with cough
Other seborrheic keratosis (L82.1)
Subjective: Small scattered, brown moles to lower back
Objective: Multiple scattered 3mm seborrheic keratosis to lower back
Overweight (E66.3)
Objective: BMI 28.3
Gastro-esophageal reflux disease without esophagitis (K21.9)
Subjective: Reports GERD controlled with medications, denies sore throat or difficulty with swallowing
Type 2 diabetes mellitus without complications (E11.9)
Subjective: History of type 2 diabetes. Average morning glucose is 120. Denies appetite change, hot or cold tolerance, or weight changes.
Osteoarthritis of knee (M17.9)
Subjective: Reports osteoarthritis of bilateral knees
Osteoarthritis of first carpometacarpal joint, unspecified (M18.9)
Subjective: Reports osteoarthritis of bilateral hands
Essential (primary) hypertension (I10)
Subjective: Reports hypertension in PMH
Objective: BP 140/88
Hyperlipidemia, unspecified (E78.5)
Subjective: Reports hyperlipidemia in PMH
References
ICD-10 code lookup. (n.d.). https://icdcodelookup.com/icd-10/codes
Le, P., & Rothberg, M. (2021). Herpes zoster infection. Epocrates. https://online.epocrates.com/diseases/2311/Herpes-zoster-infection/Highlights-Basics
Miller, E. (2017). To code or not to code. https://journal.ahima.org/to-code-or-not-to-code/
ReplyReply to Comment
Collapse SubdiscussionBarbie Johnston
Barbie Johnston
WednesdayAug 11 at 9:47pm
Clinical Decision-Making Week 13
Assessment (A):
Diagnosis:
Pruritic Rash, 2
Subjective: Rash to the back of the upper right shoulder, with an onset of two days ago. Characterized as burning sensation and “itchy”, worsening over the last two days, with pain 4/10. The rash is aggravated with touch when she gets hot. Patient denies using any relieving treatments. Denies prior episode of rash, trauma, injury, illness exposure or recent exposure to irritants. Reports a history of chicken pox and denies receiving shingles vaccine.
Objective: Unilateral erythematous, maculopapular rash with small areas with developing vesicles to right, posterior, upper shoulder with a dermatomal distribution. The rash is 4cm length by 2cm width.
Screen for viral disease, Z11.59
Subjective: One day prior to the rash, she was having intermittent episodes of “stabbing” pain to the shoulder area. Reports history of chicken pox and denies receiving the shingles vaccine.
Rash to the back of the upper right shoulder, with an onset of two days ago. Characterized as burning sensation and “itchy”, worsening over the last two days, with pain 4/10. The rash is aggravated with touch when she gets hot.
Objective: Unilateral erythematous, maculopapular rash with small areas with developing vesicles to right, posterior, upper shoulder with a dermatomal distribution. The rash is 4cm length by 2cm width.
Fever, R50.9
Subjective: Patient reports fever of 100.8, feeling febrile.
Objective: PE: Temperature 100.6
Fatigue, R53.83
Subjective: Reports generalized fatigue.
Objective: None
T2DM, E11.9
Subjective: Reports history of T2DM, taking Metformin 1000mg PO BID, with average morning glucose of 120. Reports regular diet and watches carbohydrates for diabetes control. Denies urinary frequency or appetite changes.
Objective: None
Hypertension, I10.0
Subjective: Reports history of hypertension, monitors blood pressure at home and medication controlled, taking Lisinopril 20 mg PO daily.
Objective: PE: BP of 140/88
Hyperlipidemia, E78.5
Subjective: Reports history of HLD, taking Atorvastatin 40 mg PO daily. Reports familial history; mother, stroke at 88 yr old.
Objective: None
GERD, K21.9
Subjective: Reports history of GERD, controlled with medication, taking Omeprazole 40 mg PO BID. Denies vomiting, reports a good appetite.
Objective: None
Seborrheic keratosis, L82.0
Subjective: Small scatter, brown moles to lower back.
Objective: None
Stress Incontinence, N39.3
Subjective: Reports stress incontinence with cough.
Objective: None
Osteoarthritis, M19.049 (Bilateral hands) and M17.0 (Bilateral Knees)
Subjective: Reports osteoarthritis of bilateral knees and hands, taking Tylenol Arthritis 2 tabs every 8 hours as needed for pain.
Objective: Normal strength and tone. No laxity, instability, subluxation of joints, and normal movements of all joints.
Hearing Loss Right Ear, H91.91
Subjective: Reports hard of hearing to right ear. Denies tinnitus, vertigo, discharge, and pain.
Objective: Mild hearing deficit to whisper test on right ear. Left ear hearing intact.
According to the American Academy of Dermatology, one way to confirm a shingles diagnosis is by obtaining a small amount of fluid sample from a blister and sending it to a laboratory for examination under a high-powered microscope. The presence of the virus within the fluid sample confirms the diagnosis (AAD, 2021). Upon confirmation of the diagnosis of shingles (ICD-10 B02), the diagnoses of fever and fatigue would no longer be warranted. As they are symptoms related to the diagnosis of shingles. The Herzing NU 611 Unit 3 required reading states, “if a diagnosis cannot be made due to the need for confirmation testing, then chose a ICD-10 symptom code, until you have a working diagnsosis” (p2). This is the reason I chose the diagnosis of pruritic rash (L28.2) over the diagnosis of shingles (B02.0). However, I did find studies that suggested that a diagnosis of shingles can be made based on patient symptoms. Another compelling reason for an immediate diagnosis is for the initiation of antivirals. If given within 3 days, the medicine can significantly reduce the duration of nerve pain (AAD, 2021). However, the AAD recommends confirmation of the disease with testing.
Herzing University. (2021). Cracking the Code [PDF document]. https://herzing.instructure.com/courses/17457/pages/unit-3-required-resources?module_item_id=989982
ICD-10 Data. (2021). The Web’s Free 2021 ICD-10-CM/PCS Medical Coding Reference. https://www.icd10data.com/search?s=hearing%20impairment%20right%20ear (Links to an external site.)
Shingles: Diagnosis and treatment. (2021). American Academy of Dermatology. https://www.aad.org/public/diseases/a-z/shingles-treatment (Links to an external site.)
