Neurological Disorders Affecting Bladder Function Discussion Paper
Patient Case Study
Patient Initials: Mr. D. Age: 74 years Sex: Male
Subjective Data
Chief Complaint: Mr. D presents with urinary frequency, urinary incontinence, dribbling, and a feeling of lower abdominal fullness.
HPI: Mr. D reports that he has been experiencing these urinary problems for months. He states that they initially improved but then worsened again, causing him to feel scared. Some additional information to be obtained from this patient regarding his symptoms include a detailed history of urinary symptoms, including onset, duration, frequency, severity, and any factors exacerbating or alleviating the symptoms. Obtaining associated symptoms such as pain, hematuria (blood in urine), nocturia (excessive urination at night), urgency, or burning sensation is also important to determine the characteristics of the urinary symptoms. Neurological Disorders Affecting Bladder Function Discussion Paper
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A history of previous treatment for urinary symptoms, including medications such as Flomax and cranberry pills, will also help determine the patient’s progress. Medical history, including hypertension and benign prostatic hyperplasia (BPH), Medication history, current and past use of Aldomet (methyldopa) for hypertension, Sexual history, and any concerns or issues related to medications and sexual activity will help determine the progression of the patient’s symptoms. The APN should also obtain any history of cognitive decline, memory problems, and recent changes in urinary habits, such as increased frequency or incontinence.
A comprehensive review of systems focusing on the patient’s genitourinary and cardiovascular systems should be assessed. A thorough review of the patient’s mental state should also be evaluated, given his history of cognitive decline. Neurological Disorders Affecting Bladder Function Discussion Paper
Objective Data
Additional objective data to assess would include measurement of the patient’s weight and calculation of BMI (Body Mass Index), assessment of the patient’s cognition and memory using a validated tool, given his self-reported forgetfulness, an evaluation of the patient’s urinary pattern, including the frequency, amount, and consistency of urine, assessment of the patient’s bladder emptying, such as performing a post-void residual (PVR) measurement using ultrasound.
Physical Examination
A physical examination of the abdomen and lower urinary tract, including palpation for any masses or distention, should be conducted. These additional objective data will help further evaluate the patient’s overall health status, cognitive function, and specific aspects of urinary symptoms for a more accurate diagnosis and symptom management. Neurological Disorders Affecting Bladder Function Discussion Paper
Co-morbid conditions that should be investigated through the physical exam include:
Hypertension: Measurement of blood pressure to assess the severity and control of hypertension.
Benign prostatic hyperplasia (BPH): Digital rectal examination (DRE) to assess the size and consistency of the prostate gland.
It is essential to evaluate these conditions as they can contribute to or exacerbate urinary symptoms and may require different management approaches for better outcomes. Neurological Disorders Affecting Bladder Function Discussion Paper
The appropriate national guidelines for this case include:
American Urological Association (AUA) Guidelines on the Management of Benign Prostatic Hyperplasia (BPH) provide evidence-based recommendations for diagnosing and treating BPH, a relevant condition in this case. They outline different treatment options, including medication and surgical interventions, based on the severity of symptoms and their impact on quality of life (American Urology Association, 2021).
Diagnostic Tests
The diagnostic tests that can be ordered for this case include a urinalysis to evaluate for infection, hematuria, glucosuria, or other abnormalities (Queremel Milani & Jialal, 2022). Hematuria may indicate an infection within the urinary system, while glucosuria may indicate possible diabetes. To assess kidney function, serum creatinine and estimated glomerular filtration rate (eGFR) should be evaluated. Elevated creatinine and increased eGFR may indicate kidney damage (Gounden & Jialal, 2019). Prostate-specific antigen (PSA) blood test should be conducted to screen for prostate cancer, especially in older individuals with urinary symptoms. A positive result indicates the possibility of prostate cancer (David & Leslie, 2020). A post-void residual (PVR) measurement will also be needed to assess bladder emptying and identify any issues with incomplete emptying. The sensitivity and specificity of these tests vary, but they provide valuable information to help determine the underlying cause of the urinary symptoms and guide further management. Neurological Disorders Affecting Bladder Function Discussion Paper
Medical Diagnosis: Based on the patient’s presentation and history, the medical diagnosis is likely Benign Prostatic Hyperplasia (BPH) with urinary symptoms and uncontrolled hypertension.
Differential Diagnoses:
Urinary tract infection (UTI): According to Godbole et al. (2020), urinary frequency and incontinence symptoms can be seen in UTIs, especially in older individuals.
Prostatitis: Inflammation of the prostate gland can cause similar urinary symptoms.
Prostate cancer: Although less likely in this case, prostate cancer can also present with urinary symptoms.
Neurological disorders affecting bladder function: Conditions like multiple sclerosis or spinal cord lesions can lead to urinary problems.
Overactive bladder: Characterized by frequent, urgent urination and urinary incontinence, it is important to consider this a potential diagnosis. Neurological Disorders Affecting Bladder Function Discussion Paper
Treatment Plan:
Refer the patient to a urologist for further evaluation and management of BPH. Prescribe or adjust medications, considering the patient’s medical history and medication interactions. For instance, for BPH symptoms, Flomax (tamsulosin) 0.4 mg orally once daily can be prescribed for symptom management. It is also critical to consider an alternative antihypertensive medication to Aldomet to manage the sexual side effects. An alternative antihypertensive medication for this patient is an angiotensin receptor blocker (ARB). ARBs are a class of medications commonly used to treat hypertension and have a lower incidence of sexual side effects than other antihypertensive agents (Kim et al., 2019). One specific ARB that could be considered is losartan. The recommended starting dose of losartan for hypertension is 50 mg once daily. However, the dose can be adjusted based on the patient’s response and blood pressure control. The maximum recommended dose of losartan is 100 mg once daily.
Order diagnostic tests such as urinalysis to assess for infection or other abnormalities, serum creatinine and eGFR to evaluate kidney function, PSA blood test to screen for prostate cancer, and PVR measurement to assess bladder emptying. Neurological Disorders Affecting Bladder Function Discussion Paper
Healthy People 2030 Goals
The Healthy People 2030 aim to reduce the proportion of adults with hypertension. In this case, health promotion can involve educating the patient on lifestyle modifications to manage hypertension and BPH, such as maintaining a healthy weight, regular exercise, and reducing sodium intake.
Specific Patient Teaching
Educate the patient on the importance of medication adherence for BPH and hypertension. Provide information about lifestyle modifications to manage urinary symptoms, such as avoiding excessive fluid intake before bedtime, practicing pelvic floor exercises, and maintaining regular voiding intervals. Discuss the importance of regular follow-up appointments with the urologist and primary care provider. Neurological Disorders Affecting Bladder Function Discussion Paper
Billing Codes:
CPT Code for initial office visit: 99204 (Comprehensive history, examination, and medical decision-making of moderate complexity) (The American College of Surgeons, 2021).
CPT Code for follow-up office visits: 99213 (Expanded problem-focused history, examination, straightforward medical decision-making).
The difference between the first-visit billing code and the follow-up billing code lies in the level of detail and complexity involved in the initial evaluation compared to subsequent visits. First-visit codes generally involve more comprehensive assessments, while follow-up codes are focused on monitoring and managing an existing condition.
ICD-10 codes:
Benign Prostatic Hyperplasia (BPH): N40.0
Hypertension: I10 Neurological Disorders Affecting Bladder Function Discussion Paper
Follow-up and Evaluation:
The next office visit should occur after two weeks.
During the follow-up visit, assess the patient’s response to the prescribed medications and any changes in urinary symptoms. For this patient with urinary symptoms and hypertension, a follow-up evaluation will be required with a urologist and primary care provider to assess the response to treatment and make necessary revisions to the management plan. If the patient continues to experience urinary symptoms (frequency, incontinence, dribbling, abdominal fullness), consider adjusting the medication regimen for benign prostatic hyperplasia (BPH) by increasing the dose of tamsulosin from 0.4 mg to 0.8 mg once daily. If blood pressure remains uncontrolled or increases, the treatment plan may be revised by discontinuing Flomax (tamsulosin) and prescribing an alternative antihypertensive medication. For instance, the patient may be started on losartan 50 mg once daily for blood pressure control, with possible dose adjustments based on the patient’s response. Regular follow-up visits will help monitor the patient’s progress, evaluate treatment effectiveness, and determine the need for further modifications or interventions. Neurological Disorders Affecting Bladder Function Discussion Paper
References
American Urology Association. (2021). Benign prostatic hyperplasia (BPH) Guideline – American Urological Association. Www.auanet.org. https://www.auanet.org/guidelines-and-quality/guidelines/benign-prostatic-hyperplasia-(bph)-guideline
David, M. K., & Leslie, S. W. (2020). Prostate specific antigen (PSA). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557495/
Godbole, G. P., Cerruto, N., & Chavada, R. (2020). Principles of assessment and management of urinary tract infections in older adults. Journal of Pharmacy Practice and Research, 50(3), 276–283. https://doi.org/10.1002/jppr.1650
Gounden, V., & Jialal, I. (2019, April 3). Renal function tests. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK507821/
Kim, K., Ihm, S.-H., Kim, G.-H., Kim, H. C., Kim, J. H., Lee, H.-Y., Lee, J. H., Park, J.-M., Park, S., Pyun, W. B., Shin, J., & Chae, S. C. (2019). 2018 Korean society of hypertension guidelines for the management of hypertension: Part III-hypertension in special situations. Clinical Hypertension, 25(1). https://doi.org/10.1186/s40885-019-0123-y
Queremel Milani, D. A., & Jialal, I. (2022, May 8). Urinalysis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557685/
The American College of Surgeons. (2021). Office/Outpatient E/M Codes. ACS. https://www.facs.org/for-medical-professionals/practice-management/coding-and-billing/em-coding-billing/officeoutpatient-em-visit-coding-changes/officeoutpatient-em-codes/
Mr. D, a 74 year-old retired police officer, presents with Urinary frequency, urinary incontinence, dribbling and feeling of lower abdominal fullness. Heâ€
s by himself and a little forgetful so his PMH and Medication history is incomplete. Neurological Disorders Affecting Bladder Function Discussion Paper
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CC: “I had these peeing problems for months, they seemed to improve, and then got
worse. Now Iâ€m getting scared.â€
Past medical history: Hypertension, BPH
Has been taking Flomax and cranberry pills, dose unknown, frequency everyday.
Physical exam: Blood pressure, 180/100; respiration rate, 18/min.
Patient states he was supposed to be taking Aldomet for his blood pressure but couldnâ€t have sex with it.
Physical exam is reported as negative for abnormalities.
Questions:
1.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? Neurological Disorders Affecting Bladder Function Discussion Paper
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? Neurological Disorders Affecting Bladder Function Discussion Paper