Comprehensive Health Assessment, Coded Problem List, and Care Plan for a 57-Year-Old Intercity Motorcoach Driver Establishing Primary Care
[Student Name]
University of Phoenix
NSG/523: Advanced Health Assessment
Week 6 Assignment
[Instructor Name]
[Date]
Composite patient written as a model document. No real patient, clinician or practice is described.
Reason for Visit and History of Present Illness
The patient is a composite 57-year-old man who drives an intercity motorcoach on overnight routes, usually four nights away on layovers and three at home. He is establishing primary care because the clinician who performed his commercial driver medical examination last month issued a one-year certificate instead of the usual two because his blood pressure was elevated, and advised him to find a regular provider. His last visit with any regular clinician was about nine years ago. He feels well but admits to daytime sleepiness on long afternoon drives, for which he drinks four to five energy drinks a day. On his nights at home, his wife hears loud snoring interrupted by pauses in his breathing that end with a snort.
Past, Family and Social History
Past medical history: no diagnosed chronic illness; two earlier readings were, in his words, "a little high". No surgeries except a left knee arthroscopy at 40. Medications: ibuprofen 400 to 800 mg several times a week for back and knee pain. No known drug allergies. Immunizations: tetanus booster more than ten years ago; no pneumococcal, zoster or recent influenza vaccine.
Family history: father died of a heart attack at 61; mother living with type 2 diabetes; brother with hypertension.
Social history: married, two adult children. Smokes one pack of cigarettes a day for 35 years. Drinks two to three beers on days at home, none on the road. Eats most meals at bus terminals and fast food restaurants near layover hotels. Little planned exercise. Owns a firearm, stored locked at home.
Review of Systems
General: daytime sleepiness, weight gain of about 14 kg over five years. Skin: no lesions of concern. HEENT: morning headaches two or three times a week; no vision change. Cardiovascular: no chest pain, palpitations or leg swelling. Respiratory: morning cough, no hemoptysis or wheeze. Gastrointestinal: occasional heartburn after large meals; no blood in stool. Genitourinary: gets up once or twice a night to urinate; no hesitancy. Musculoskeletal: low back and left knee pain after long shifts behind the wheel. Neurologic: no weakness or numbness. Psychiatric: mood good; PHQ-2 score 0. Endocrine: increased thirst after salty meals only. Hematologic: no easy bruising.
Physical Examination
Vital signs: blood pressure 152/96 mm Hg and 148/94 mm Hg on two seated readings five minutes apart with an appropriately sized cuff, averaging 150/95; pulse 82 and regular; respirations 16; temperature 36.8 C; oxygen saturation 95% on room air. Height 1.80 m, weight 118 kg, body mass index 36.4. Neck circumference 45 cm; waist circumference 118 cm.
General: alert, cooperative, in no distress. Skin: warm and dry; no rashes or suspicious nevi; nicotine staining of the right second and third fingers. HEENT: normocephalic; pupils reactive; fundi show mild arteriolar narrowing without hemorrhages or exudates; tympanic membranes normal; crowded oropharynx with enlarged tongue and a low-lying soft palate, Mallampati class IV. Neck: supple, no lymphadenopathy or thyroid enlargement, no carotid bruits. Lungs: clear to auscultation with mildly prolonged expiration, no wheezes. Heart: regular rhythm, normal S1 and S2, no murmurs or gallops; apical impulse not displaced. Abdomen: obese, soft, nontender, no organomegaly palpable, no bruits. Extremities: no edema; pedal pulses present bilaterally; left knee with crepitus and full range of motion. Back: paraspinal tenderness in the lower lumbar region, negative straight leg raise bilaterally. Neurologic: cranial nerves intact; strength, sensation and reflexes symmetric; gait normal. Psychiatric: normal affect and judgment.
Screening tools: the STOP-Bang questionnaire, which scores snoring, tiredness, observed apneas, high blood pressure, body mass index over 35, age over 50, neck circumference over 40 cm and male sex, was positive on all eight items (Chung et al., 2008).
Laboratory results from the driver examination and a fasting draw: hemoglobin A1c 6.1%, fasting glucose 112 mg/dL, total cholesterol 246 mg/dL, low-density lipoprotein cholesterol 162 mg/dL, high-density lipoprotein cholesterol 38 mg/dL, triglycerides 230 mg/dL, creatinine 0.9 mg/dL and urinalysis negative for protein.
Coded Problem List
1. Essential (primary) hypertension, I10. The average of 150/95 mm Hg on repeated readings, with prior elevated readings and retinal arteriolar narrowing, meets the definition of stage 2 hypertension in the current guideline, which defines stage 2 as systolic 140 or higher or diastolic 90 or higher (Whelton et al., 2018).
2. Snoring, R06.83, with witnessed apneas and daytime sleepiness. Obstructive sleep apnea is strongly suspected, but it is not coded until a sleep study confirms it, because outpatient coding rules direct the clinician to code signs and symptoms rather than a condition described as suspected or probable (Centers for Medicare & Medicaid Services & National Center for Health Statistics, 2024).
3. Obesity, unspecified, E66.9, with body mass index 36.0 to 36.9 in an adult, Z68.36.
4. Prediabetes, R73.03, based on a hemoglobin A1c of 6.1%, within the 5.7% to 6.4% range the diabetes standards use for prediabetes (American Diabetes Association Professional Practice Committee, 2025).
5. Hyperlipidemia, unspecified, E78.5.
6. Nicotine dependence, cigarettes, uncomplicated, F17.210.
7. Chronic low back pain and left knee pain with frequent nonsteroidal anti-inflammatory drug use, a concern given his blood pressure; coded for this visit as low back pain, unspecified, M54.50, and pain in left knee, M25.562.
Care Plan
For hypertension, the plan follows the guideline recommendation that adults with stage 2 hypertension whose blood pressure is more than 20/10 mm Hg above target start two first-line agents of different classes, with a goal below 130/80 mm Hg (Whelton et al., 2018). He starts a single-pill combination of an angiotensin-converting enzyme inhibitor and a calcium channel blocker, with basic metabolic panel in two weeks and a home blood pressure monitor he can carry to layover hotels. He is counseled to stop regular ibuprofen and use acetaminophen and stretching breaks instead, and to reduce energy drinks, which raise blood pressure and mask sleepiness.
For suspected sleep apnea, he is referred for a home sleep apnea test, which the sleep medicine guideline supports for uncomplicated adults with signs and symptoms indicating an increased risk of moderate to severe obstructive sleep apnea (Kapur et al., 2017). He is counseled not to drive when drowsy, and it is explained that confirmed, treated sleep apnea is compatible with continued commercial driving.
For prediabetes, obesity and hyperlipidemia, he is referred to a CDC-recognized diabetes prevention program with an online option he can use on the road, and a 10-year atherosclerotic cardiovascular disease risk estimate is calculated to guide a statin discussion at the next visit. For tobacco dependence, he is offered varenicline with counseling and a quitline referral, and he sets a quit date. Preventive care includes tetanus, pneumococcal, zoster and influenza vaccines as indicated, colorectal cancer screening and a discussion of lung cancer screening, since his 35 pack-year history makes him eligible.
Follow-up is in two weeks for blood pressure and laboratory review, then monthly until his blood pressure is controlled.
Conclusion
A comprehensive assessment of a coach driver who came in only for a blood pressure certificate found stage 2 hypertension with early target organ changes, a high probability of obstructive sleep apnea, prediabetes, obesity, dyslipidemia and heavy tobacco use. Coding each problem correctly, including coding suspected sleep apnea by its symptom, and building a plan that fits his life on the road turn a head-to-toe examination into care he can actually follow.
References
American Diabetes Association Professional Practice Committee. (2025). 2. Diagnosis and classification of diabetes: Standards of care in diabetes-2025. Diabetes Care, 48(Suppl. 1), S27-S49. https://doi.org/10.2337/dc25-S002
Centers for Medicare & Medicaid Services & National Center for Health Statistics. (2024). ICD-10-CM official guidelines for coding and reporting FY 2025. https://www.cms.gov/medicare/coding-billing/icd-10-codes
Chung, F., Yegneswaran, B., Liao, P., Chung, S. A., Vairavanathan, S., Islam, S., Khajehdehi, A., & Shapiro, C. M. (2008). STOP questionnaire: A tool to screen patients for obstructive sleep apnea. Anesthesiology, 108(5), 812-821. https://doi.org/10.1097/ALN.0b013e31816d83e4
Kapur, V. K., Auckley, D. H., Chowdhuri, S., Kuhlmann, D. C., Mehra, R., Ramar, K., & Harrod, C. G. (2017). Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13(3), 479-504. https://doi.org/10.5664/jcsm.6506
Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Jr., Collins, K. J., Dennison Himmelfarb, C., DePalma, S. M., Gidding, S., Jamerson, K. A., Jones, D. W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C., Jr., Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K. A., Sr., ... Wright, J. T., Jr. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension, 71(6), e13-e115. https://doi.org/10.1161/HYP.0000000000000065
How this NSG 523 Week 6 example is structured
The University of Phoenix library guide for NSG/523 lists Week 6 as Comprehensive Assessment, and the course page names coding and care plan development among its skills, so this final-week model pulls every system together and ends in a coded problem list and plan. The history and examination are written compactly so the reasoning sections have room. The coding section explains why a suspected condition is coded by its symptoms, which is the rule students most often miss, and each part of the plan answers a numbered problem. Students search this week as NSG 523 Week 6, NSG523 Wk 6 or NSG/523 Wk 6; all three are the same assignment.
NSG/523 Week 6 questions, answered
What does NSG/523 Week 6 usually ask for?
The University of Phoenix library guide for NSG/523 lists Week 6 as comprehensive assessment. Many sections ask for a complete head-to-toe history and physical examination write-up, and the course page lists coding and care plan development among the skills the course builds. Your instructions decide whether ICD-10 codes and a plan are required.
Why is suspected sleep apnea not coded as sleep apnea?
Outpatient coding rules say that conditions described as suspected, probable or rule out are not coded as if confirmed; the clinician codes the signs and symptoms instead. The sample codes snoring until a sleep study confirms the diagnosis.
How long should a comprehensive assessment write-up be?
Long enough to cover every system without narrative padding. Normal systems can be recorded in one or two lines, which leaves room for abnormal findings and reasoning. The sample runs about 1,500 words including the coded problem list and plan.
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