Answered: Stan returned to the clinic for a…

Understanding Health Insurance: A Guide to Billing and Reimbursement

14th Edition

ISBN:9781337679480

Author:GREEN

Publisher:GREEN

Chapter6: Icd-10-cm Coding

Section: Chapter Questions

Problem 48R

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Question

Patient Profile:

Stanley is a college student taking up engineering in one of the university in Metro Manila. He lives alone in the dormitory and his province is Bicol. He was diagnosed of Syphilis.

History:

-Stanley is a 19-year-old male who presents to the STD clinic because he’s - had a sore on his penis for one week.

-Last sexual exposure was three weeks prior, without a condom.

-No history of recent travel.

-Predominantly female partners (five in the last six months), and occasional male partners (three in the 1-2 years).

-Last HIV antibody test (two months prior) was negative. Reports three children with two different women. All children were in the province taking care of by his parents. He is single and always on the go to mingle.

Physical Exam:

-No oral, perianal, or extra-genital lesions.

-Genital exam shows an uncircumcised penis with a lesion on the ventral side near the frenulum. Lesion is red, indurated, clean-based, and non-tender.

-Two enlarged tender right inguinal nodes, 1.5 cm x 1 cm.

-Scrotal contents are without masses or tenderness.

-No urethral discharge.

-No rashes on torso, palms, or soles. No alopecia. Neurologic exam within normal limits.

Laboratory:

The results of stat laboratory tests showed the following:

-Darkfield examination of penile lesion—Positive for T. pallidum

-FTA-ABS—Reactive

-HSV culture—Negative

-Gonorrhea NAAT—Negative

-Chlamydia NAAT—Negative

-HIV antibody test—Negative

Medications:

May give Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals, but after the skin testing, Stanley shows with allergy in penicillin so the doctor advised to take vancomycin 250 mg orally 4 times a day for 10 days PLUS Rifampin 600 mg orally twice a day.

Partner Management

Stanley had the following sex partners during the past year:

Tracy—(met in QC Circle) Last sexual exposure three weeks ago (receptive oral and vaginal sex with Stanley)

Richelle—(met in SM Manila) Last sexual exposure four weeks ago (vaginal sex with Stanley) Carmina—(met in Luneta) Last sexual exposure five weeks ago (vaginal sex with Stanley) Danielle—(met in Divisoria) Last sexual exposure six weeks ago (vaginal sex with Stanley) Jonathan—(met in Trinoma) Last sexual exposure six month ago (receptive anal sex with Stanley)

Tony—(met in Quiapo) Last sexual exposure eight months ago (insertive oral and anal sex with Stanley)

Calvin—(met in Recto) Last sexual exposure ten months ago (receptive oral and anal sex with Stanley)

Follow-Up:

Stan returned to the clinic for a follow-up exam one week later. Results were as follows:

-His penile lesion was almost completely healed.

-He had not experienced a Jarisch-Herxheimer reaction.

-The RPR (repeated at the follow-up visit because the initial one was negative) was 1:2.

Course Task:

1. Conceptualize the pathophysiological alterations distinct to the case.

-Establish the pathophysiological triad of Host – Agent – Environment specific to the case.

-Trace the pathophysiological changes and highlight problems that are experienced by the client.

-Connect the pertinent nursing care and medical – surgical management to the various signs and symptoms presented by the client.

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