Primary Care Unit 6 Assignment

Recall an adolescent patient (12-21) visit where either preventative care or further evaluation and follow-up was needed.

1. Did you refer this patient to a specialist or communicate with a specialist to determine the best approach of care?
2. Describe the patients chief complaint and key points of their subjective history and any pertinent physical exam findings. What were the differential diagnoses you were trying to rule in or out with your further evaluation? Include your rationales for differentials and diagnosis.
3. Was the laboratory and/or diagnostic testing ordered for preventative or diagnostic care? What was the rationale for ordering diagnostics and labs?
4. If you ordered for preventative care, how did your documentation differ from ordering a lab or diagnostic for diagnostic care? Was this coded differently? If you ordered for diagnostic care, how did your documentation differ from ordering a lab or diagnostic for preventative care?
5. Was this coded differently?
6. Discuss your responsibilities as an APRN for follow up and reporting of both normal and abnormal results of the adolescents exam.
7. What are the confidentiality/privacy laws surrounding adolescents and reporting diagnostics and lab results to their parents?

Use a 17 year old coming in complaining of right flank pain and two episodes of bloody urine. His mother is at the appointment with him.