Female Wellness Assessment

Analysis of the Assessment D.E. had five diagnoses documented during the visit. Since she came for an annual physical exam, the primary diagnosis was female wellness exam. ICD-10 code was Z00.00. While she was in the office, she also complained of having one drop of vaginal blood every day after menopause. The second diagnosis was postmenopausal bleeding, and the ICD-10 code was N95.0. After D.E. was examined, wheezing sounds were auscultated and she has a diagnosis of COPD. The third and fourth diagnoses were breast abscess (N61.1) and COPD (J44.9). The last diagnosis is obtained during history taking: hyperlipidemia (E78.5). The reason to document other diagnoses than female wellness exam is to address all disease management and health

According to the U.S. Preventive Services Task Force (U.S. Preventive Services Task Force, 2016), they found convincing evidence that bone measurement tests predict short-term risk for osteoporotic fractures in women who are 65 years and older. The tests should be performed every two years. The most common tests used are dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine. In addition, in postmenopausal women who have no previous osteoporotic fractures, the USPSTF also found convincing evidence that drug therapies reduce the risk for fractures. It is appropriate to recommend D.E. to take calcium and vitamin D3 for osteoporosis prevention, as she declined to have osteoporosis

She also used motivational interview techniques to assess D.E.’s readiness for smoking cessation. Although D.E. was not ready to quit smoking yet, she did not seem to be resistant to the recommendation either. The revaluation of smoking cessation could be followed up on next visit. The student also used the “teach back” technique when she educated D.E. about heart-healthy lifestyle. D.E. was able to name a few activities and types of healthy food that she enjoyed. She also understood that smoking could affect her lipid level. If anything the student could have done differently was to ask more detailed questions about the reason she wanted to continue smoking vapor. Smoking was a major concern in D.E.’s life at this point, because she has hyperlipidemia, postmenopausal bleeding, and