Template
Below is the template you are to follow when developing your management plan. It is to
be completed as a Word document and then you can copy and paste it in to iHuman.
Also, always be sure to complete the EMR
...
Template
Below is the template you are to follow when developing your management plan. It is to
be completed as a Word document and then you can copy and paste it in to iHuman.
Also, always be sure to complete the EMR on the case. Use this template with each
case. It is not a SOAP format as that is not required. 30 points will be deducted for not
utilizing the template.
Primary Diagnosis and ICD-10 code: Also include any procedural codes.
Osteoarthritis- (M17.0) Osteoarthritis of the knee is a common degenerative bone and joint
disease, which is caused by the degradation synthesis coupling of chondrocytes, extracellular
matrix, and subchondral bone under the action of mechanical and biological factors (Xin et al.,
2021). Out of all of them, the articular cartilage damage is the most important pathological
changes noted, which is mainly interceded by inflammatory reactions (Xin et al., 2021). This
diagnosis was chosen as the primary diagnosis because of the patient family history of arthritis
and the fact that she reports having bilateral knee pain, with morning stiffness, as well as the
same type pain in her hands. All of these symptoms are indicative of individuals who have
osteoarthritis. She also mentioned that the symptoms seemed to have gotten worse over the last 5
years and osteoarthritis does get progressively worse as time goes on.
Differential Diagnoses- Why? What? How?
1. Rheumatoid arthritis- (M06.9) RA is a systemic inflammatory autoimmune disorder that
mainly affects the peripheral synovial joints (Taylor, 2020). RA is a disorder that
develops gradually and while in the early stages, determining a diagnosis can be very
difficult (Taylor, 2020). Most patients will report symptoms of stiffness in one or more
joints, often noticing the stiffness in the morning, accompanied by discomfort on
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care
movement and joint tenderness (Taylor, 2020). The joints that are mainly affected are the
joints in the hands, wrist, and feet (Taylor, 2020). Other large joints that can be affected
as well are the joints of the knees, shoulders, elbows, and ankles. This diagnosis was
chosen as a differential diagnosis because this patient had several of these symptoms
mentioned above. In order to ultimately rule this diagnosis out I would have to wait on
the diagnostic test results that was ordered to determine a diagnosis of RA or rule it out.
2. Gout- (M10.9) Gout is an inflammatory arthritis that occurs when there are deposits of
monosodium urate crystals in the joints and soft tissues that is caused by elevated levels
of uric acid in the blood stream (Mbuyi & Hood, 2020). There are thousands of
individuals living with gout in the US, making this disorder the most common
inflammatory arthritis nationally (Mbuyi & Hood, 2020). Gout usually affects the first
metatarsophalangeal joint in the hands, which can eventually lead to gouty flareups that
develops in the ankles, midfoot joints, knees, wrist, and elbows (Mbuyi & Hood, 2020).
The pain from a gout flareup can become so severe that the patient often complains of an
inability to tolerate even the slightest pressure on the affected joint (Mbuyi & Hood,
2020). During the exam the examiner may notice that the affected joints are warm,
erythematous, and extremely tender to touch, and a joint effusion may be present (Mbuyi
& Hood, 2020). Once again, this diagnosis was chosen because of the patient reporting
that her hands were puffy and swollen, she had positive joint effusions, and she could
barely make it through the exam because of the pain during palpation. I personally
ordered specific diagnostic test such as a serum uric acid test to determine if this patient
really does have gout.
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