Elevated LFT’sSubjectiveJane, a 48-year-old Caucasian female, presents to the primary care clinic to

Elevated LFT’sSubjectiveJane, a 48-year-old Caucasian female, presents to the primary care clinic to establish care. She states that in 1980 she received a blood transfusion after sustaining injuries associated with the motor vehicle accident. She had tested positive for hepatitis C virus (HCV) in the past but ignored any advice regarding treatment options. She brings her previous lab results with her today that shows an alanine aminotransferase (ALT) level of 55 IU/ml (range 8-35 IU/ml). The lab also states, “HCV antibody is positive by enzyme immunoassay-confirmation is suggested. “she states that she feels fine but thought it would be best to get checked out. Her review of systems are negative. Past medical history: hypertension, dyslipidemia, hepatitis C.Past surgical history: ectopic pregnancy, age 26.Family history: noncontributory.Social history: she works as a sales representative and is married with three children. Denies use of illegal drugs, denies alcohol abuse, and has no tattoos.Medications: hydrochlorothiazide, 20 mg daily; Crestor, 20 mg daily.Allergies: no known drug or food allergies.ObjectiveGeneral appearance: 48-year-old female; pleasant, in no acute distress; good eye contact.Vital signs: T: 98.2; P: 86, RR: 28; SaO2: 93; BP: 128/70. Her weight is 164 pounds, airtight is 65 inches.HEENT: negative.Neck: thyroid nonpalpable. No lymphadenopathy.Cardiovascular: regular rate and rhythm. PMI is a 5th intercostal space, left sternal border. Pulses +2 all extremities.Respiratory: lungs clear to auscultation. AP/transverse diameter 1:2. No wheezes; no crackles.Abdomen: mild tenderness in right upper quadrant. BS +, no bruits. Nondistended, soft. No organomegaly. No ascites.Neurological: A&O X 4, CN II-XII grossly intact. Depression scale: negativeMusculoskeletal: Full ROM. No deformities. Muscle strength is 5/5.Diagnostic Test ResultsAST: 56 U/LALT: 76 U/LHCV RNA: positive Introduction: Introduce your presentation including a brief description of your presentation. Describe the purpose and plan for this presentation.Subjective: What additional subjective information do you need from the patient? What additional history (past medical, surgical, and family) needs to be included?Objective: What additional physical exam findings are needed?Diagnosis(s) What is the most appropriate diagnosis(s) given the patient’s presentation. (include four differential diagnosis and ICD-10 codes)Assessment Findings: Include rationales based on your subjective and objective assessment findings to support your diagnosis(s).Plan: What labs and/or diagnostic testing, if any, would you order? Please include CPT/Procedural codes for each.Referrals & Patient Education/Follow-up Plan: Based on your patient’s given diagnosis, include referrals when applicable (if no referrals are necessary please state your reasons why and list pertinent patient education that is applicable to your diagnosis(s). Lastly, include return to clinic guidelines as part of your patient education.Prescriptions: Include written prescriptions of all medications that include prescriptions, lab/diagnostic testing, OTC, (over the counter) and Herbal formulations; include teaching points with common potential side effects. Utilize the script pad in Canvas for each medication.Summary: Explain how this paper met the purpose stated in the introduction.Organization: Verbal presentation should flow smoothly from point to point without interruptions or “hiccups.” Presenters should be prepared for questions from the instructor.Participation: Presentation should include roughly equal participation from all group members; no group members should dominate the presentation or do most of the talking.Delivery: All presenters should be visible, audible, and confident when delivering information.  Health Science Science Nursing NRSG MISC Share QuestionEmailCopy link Comments (0)

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