Preceptorship Experience Essay Discussion Paper

Subjective

History of present illness: A 73-year-old patient is admitted who for several months refers to progressive appression of inflammation in the left elbow. She says that when she touches it, it hurts. she has not taken any medication for this, and reports not having any important antecedent.

Surgical history: s/p kidney stone retrieval 1980s

Medical History: Hyperlipidemia

Social History: Patient lives with husband and son. She owns finances and drives.  She denies using alcohol, tobacco and illicit drugs Preceptorship Experience Essay Discussion Paper.

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Family History:

Patient’s mother died of heart attack at age 56, father died of hypertension at age 70.

Allergies: Penicillin

Medications:

Atorvastatin (Lipitor) for hyperlidimia

Review of Systems:

Constitutional – NAD, has been generally feeling well the last couple of weeks

Eyes – no changes in vision

ENT – No congestion or changes in hearing, does not wear hearing aids

Skin/Breast – no rashes, hives or itches

Cardiovascular – No SOB, chest pain, heart palpitations

Pulmonary – normal breathing, no short of breath, no cough

Endocrine – No changes in appetite

Gastro Intestinal – No n/v/d or constipation.

Genito Urinary – No increased frequency or pain on urination.

Musculo Skeletal – no changes in strengths, soft and painful elbow

Neurologic – No changes in memory

Psychology – No changes in mood Preceptorship Experience Essay Discussion Paper

Heme/Lymph – Denies easy bruising

Objective

Physical examination:

Pulse: 60

Respiratory rate: 18

Blood pressure: 130/70

Temperature 36 degrees celcius

 

General – NAD, sitting up in bed, well groomed

Eyes – PERRLA, EOM intact

ENT – External ears normal, no lesions or deformities; external nose normal, no lesions or deformities; canals clear bilaterally

Neck – No noticeable or palpable swelling, redness or rash around throat or on face

Lymph Nodes – No lymphadenopathy

Cardiovascular – RRR no m/r/g, no JVD, no carotid bruits

Lungs – Clear to auscltation, no use of acessory muscles, no crackles or wheezes.

Skin – No rashes, skin warm and dry, no erythematous areas

Abdomen – Normal bowel sounds, abdomen soft and nontender

Genito Urinary – Genital exam not performed since complaints not related.

Rectal – Rectal exam not performed since no symptoms indicated blood loss.

Extremeties – No edema, cyanosis or clubbing Musculo Skeletal – 5/5 strength, normal range of motion, no swollen or erythematous joints Preceptorship Experience Essay Discussion Paper.

Neurological – Alert and oriented

 

Differential Diagnosis

The differential diagnoses for the olecranon bursitis include inflammatory arthropathies, gout, cellulitis and septic arthritis.

Inflammatory arthropathies is an autoimmune disease that is associated with pain in the joints and causes various damages throughout the body. The disease causes its effect laterally in that it affects both sides of the body with infection in one arm spreads to the same joint in the other arm as well as characteristics that distinguishes it from the other forms of arthritis.

Gout, a type of arthritis, causes the joint inflammation that begins and occurs almost suddenly. Gout is associated with needle like crystals that occur due uric acid deposition in joint. The disease is causes redness and swellings in joints.

Cellulitis is a skin infection that is potentially caused by bacteria making the affected skin appear swollen, red, and feels warm when touched. The affected area is typically painful. The disease affects lower legs but in some instances spread to the face, arms among other areas. The bacteria gains access to the affected area through open skin.

Septic arthritis is an invasive disease caused by an infectious agent that attacks the joint leading to inflammation. The symptoms include; redness, pain in particular single join, warm feeling or heat and inability to the affected joint Preceptorship Experience Essay Discussion Paper

Treatment Plan

Step 1: aspirate the bag with an 18-gauge needle.

Step 2: inject a mixture of 80 mg of methylprednisolone and 2% lidocaine is) in the elbow joint from a lateral approach.

Step 3: apply a dry gauze dressing, followed by a tension bandage or elbow brace for a period 6 months.

The patient will also be given antibiotics, corticosteroids and Non-steroidal anti-inflammatory drugs. This treatment plan is supported by evidence from well-designed case-control or cohort studies (level 1V) (Sayegh & Strauch, 2014).

Teaching

The education plan will include the following:

  • Educating the patient regarding olecranon bursitis’sdiagnosis, causative factors, and treatment plan
  • Educating the patient and her family on the planned management. Also, inform them to refer immediately for any untoward signs and symptoms such as fever and aggravation of the disease, presence of purulent discharges from wound area (Wieting, 2020).
  • Emphasizing the importance of medication compliance. Inform the actions of antibiotics, corticosteroids and Non-steroidal anti-inflammatory drugs (NSAIDs). Note to the patient and family to call healthcare practitioner for untoward effects.
  • Briefing the patient that antibiotics may either kill or inhibit the growth of bacteria. The patient should take antibiotics on time with or after meals and ensure course completion. A usual side effect includes abdominal discomfort. Failure to comply may lead to further infection.
  • Teaching the patient and family those NSAIDs – a drug class that reduces, decreases fever, prevents blood clots, and in higher doses, decreases inflammation. Side effects vary on the particular prescription, but they largely involve an elevated chance of gastrointestinal bleeding and ulcers.
  • Informing the patient and family that corticosteroids – such as cortisol affect carbohydrate, fat, and protein metabolism, and have anti-inflammatory, immunosuppressive, anti-proliferative, and vasoconstrictive effects. Adverse reactions are: adrenal cortical atrophy, increased intraocular pressure, psychological dependence, immunosuppression, visual disturbance. This kind of treatment needs further examination and blood test before administration due to immunosuppressive effects that may cause further infection if any.
  • Explaining the importance of good hygiene and hand washing especially during wound care.
  • Informing the patient’s to assist the patient in her daily activities and grooming routine such as changing of bathing, changing of clothes, toilet.
  • Advising the patient to avoid strenuous activities and may take NSAIDs as advised before she perform activities. Use cushions or pads when resting a joint on a hard surface.
  • Informing the patient to attend follow-up with her physician or occupational therapist (if required). (Continuous follow-up with the doctor help to fasten recovery of the disease because he/she can provide appropriate intervention to the current signs and symptoms.) Preceptorship Experience Essay Discussion Paper

Medicare

 

For this case, the Healthcare Common Procedure Coding System (HCPCS) will be used to evaluate the codes required to give out the medical bills for the patient or their insurer (Cox, 2017). The first level of the procedure, known as the Level 1 are the codes provided for the

Medical procedures carried out over the entire time with the patient (Sayegh & Strauch, 2014). For the 73 year old patient with left elbow olecranon bursitis, certain codes should be provided for the conservative procedures such as icing of the patient elbows, or for elbow pads and compression sleeves worn, and giving of pain medications as well as injections used to drain excess fluid, in a bid to ease the patient from pain (Cox, 2017). These should be included in the first level of HCPCS to allow the medical system to process the appropriate bill to send to the medical insurer for payment of treatment procedures. For first level, the codes will mainly appear in numerical terms.

The second level, or Level II includes the bill accrued, not for the services rendered to the patient, but the medical equipment used during the process of treatment (Sayegh, & Strauch, 2014). It is also important to note that some non-medical services can be billed at this level, and the codes usually appear in terms of alphanumerical values. In the treatment of olecranon bursitis, some of the bills to include in the level II coding procedure should reflect the value or quantity of items such as compression bandage, which is provided for the patient to ease them from pain and avoid further trauma (Sayegh, & Strauch, 2014). Here, the surgical equipment, deemed necessary and which might have been used as an alternative to steroid injections should also be included in the medical bill presented at the level II of the HCPCS Preceptorship Experience Essay Discussion Paper.

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Research Article

The research article that supports the diagnosis and treatment plan for this patient is “Olecranon bursitis. Journal of shoulder and elbow surgery” by Reilly & Kamineni (2016). It provides a powerful information regarding the treatment of olecranon bursitis. The authors suggest that while physical therapy and occupational therapy may not be unnecessary for individuals with olecranon bursistis, the may help reduce recovery time among patients who experience frequent olecranon bursitis. Authors also recommend that non-surgical treatment methods can be used to manage the infection through injection a mixture of methylprednisolone and lidocaine into the affected area. Surgical treatment can be used to in cases where antibiotics fail to work where a surgery is performed to remove the entire bursa Preceptorship Experience Essay Discussion Paper.

References

Reilly, D., & Kamineni, S. (2016). Olecranon bursitis. Journal of shoulder and elbow surgery, 25(1), 158-167.

Sayegh, E. T., & Strauch, R. J. (2014). Treatment of olecranon bursitis: a systematic review. Archives of orthopaedic and trauma surgery, 134(11), 1517-1536.

Wieting, J. M. (2020, April 17). Olecranon bursitis: Practice essentials, etiology, prognosis. Diseases & Conditions – Medscape Reference. https://emedicine.medscape.com/article/327951-overview Preceptorship Experience Essay Discussion Paper