What additional information should you obtain about the pain the patient is experiencing?
What additional physical assessments need to be completed for this patient?
What differential diagnoses should be considered for the patient?
Assuming that the in-office EKG did not indicate any abnormalities, how would you proceed to manage the abnormal subjective and objective findings discovered during this visit? Include specific interventions for each diagnosis in your treatment plan. Provide complete prescription details, follow-up instructions, and potential referrals.
What patient teaching will be incorporated into the visit to modify the patient’s risk factors?
Include the ICD-10 codes you would choose for each problem addressed and the Evaluation and Management/Office visit code expected for this visit. Keep in mind the length of time it has been since this patient has been seen in the clinic.
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