A married couple presents to the office. They have requested to be seen togethe

A married couple presents to the office. They have requested to be seen together. The female is 28 years old and the male is 29 years old. They report they have not had any routine care since college. They are concerned that they can not get pregnant.
CC: “We do not know where to begin so we thought we would have complete physicals. We know we need immunizations. Someone told us we should also get checked for chlamydia infections.”
Past medical history: None
Vital signs: Female: Blood pressure: 126/88; height, 5΄΄; weight, 185 lbs.
Male: Blood pressure: 130/98; height 6 feet, weight 170 lbs
Subjective data: What subjective data should the APN obtain? How is the complaint investigated ie HPI?
This area should discuss history, ROS, and HPI format.
2. You will reassess to verify the presented information. For what additional objective data will you assess and why?
3. What co-morbid conditions should be investigated through the physical exam, how and why?
4. What National Guidelines are appropriate to this case? What do the guidelines state?
What level of evidence supports these guidelines?
5. What diagnostic tests will you order? Why do they apply to this case? What is the sensitivity and specificity? When it is positive or negative what does that mean?
6. What is your medical diagnosis? What are the differential diagnoses?
7. Treatment plan should clearly state what exact orders you are ordering. All medications must have a name, a dose, a route, and a frequency. The diet must be specific. The diagnostics must be specific. Do not say XRAY say type of Xray ie AP/Lat chest Xray
8. Are there any Healthy People 2030 goals that you should consider? How will you promote health with this case? How does it meet the 2030
9. What specific patient teaching is needed? Do not say “how to use an inhaler” state exactly what you will teach
10. What billing codes would you recommend? This must include the CPT code for outpatient office visits. ICD classify diagnoses ie HTN i10, CPT codes are 992–, Describe the difference between the first visit billing code and follow up billing code.
11. Follow up and evaluation. When will the next office visit occur? What will you assess? How will you revise the plan based upon this assessment? For instance, if you are assessing the HgbA1c and it is 9, what will you order? If it is 6.5 what will you do?





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