[ad_1]
| Site | Office | |
| Age | 13–18 years | |
| Sex | Female, hispanic | |
| Practice Management | Type of visit/phys. exam | Adolescent (age 12–17 years) well visit – 99384 |
| Diagnosis | 1 Urinary tract infection, site not specified | |
| Student Notes | Management Plan Encounter for routine child health examination with abnormal findings Z00.121 Encounter for screening, unspecified Z13.9, N39.0 for Urinary tract infection, site not specified. 16 y/o female patient. Pt presents at the office for a good visit today. skin. She reports having lumbar left-side pain and blood in her urine for the last 2 days. Denies a family history of sudden death or MI/stroke before 55 years old. Patient with average Growth (BMI > 55%).PE shows a Normal development stage.BMI (87.5%) Immunizations. Up to date. Covid vaccine refused. Medications: Bactrim DS(800/160 mg) 1 tab PO BID for 7days. Additional tests needed: Urine rapid strip shows ketonuria 2+ and leukocytosis 2+. A urine culture was sent to the lab. Referrals: N/R at this time. Follow: Return 1 week for test result revision. Social Determinants of Health: Pt is insured with availability to access preventive services and immunizations. Pt’s mother denies food insecurities concerns; the family denies domestic violence at home or in the community. Families eating patterns explored recommendations to substitute whole milk for skin milk to decrease cardiovascular risk and white bread for whole grain bread to reduce sugar in the diet. Health Promotion: The patient was educated on safety precautions for mental disorders, substance use, smoking/nicotine use, and nutrition. Sexually transmitted infections, including human immunodeficiency virus (HIV), unintended teen pregnancies, homelessness, academic problems, and dropping out of school; Daily exercises were encouraged for 1 hour per day, and limited and supervised tv, video games, and internet use were reviewed | |
Template
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:
Location: having lumbar left-side pain
Onset: 2 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: blood in her urine for the last 2 days
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.
Allergies:Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed
Soc & Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.
Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relativesshould be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx:Prior surgical procedures.
Mental Hx:Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx:Concern or issues about safety (personal, home, community, sexual—current and historical).
Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (yes or no), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), and any sexual concerns.
ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General:Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. LMP: MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam: From head to toe, includewhat you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:).Pain on the left side of back. Add signs for kidney examination.(CVATand suprapubic tenderness positives)
Diagnostic resultsInclude any labsUrine rapid strip shows ketonuria 2+ and leukocytosis 2+. A urine culture was sent to the lab, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses).
Your primary or presumptive diagnosis: UTI
should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.
Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?
Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).
References
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
[ad_2]
Testimonials
