Focused Note on 8 year old Latino boy. Paraphrase the attached note and follow the focused not example on right. ThanksFocus

Document: Provider Notes – NURS 6512

Name:

Danny Rivera

Focused Exam: Cough

Danny Rivera is an 8-year-old male of Puerto Rican descent brought to the clinic by his Abuela because he has been feeling sick.

Subjective:

Chief Complain: Presents with a cough, runny nose, and right ear pain.

Allergies: No Known Allergies to drug, food, seasonal/environmental.

HPI: Danny’s cough began 4-5 days ago. His cough is constant, and he describe it as “gurgly and watery”. He reports occasional clear sputum. His cough has been keeping him up at night and “made it hard to fall asleep” thus making him to be fatigue due to lack of sleep. His mother gave him an over-the-counter cough medication which helped relieved his cough temporally. The name of the medication is unknown but describe it as “purple medicine”. Associated symptoms include a runny nose, mild throat soreness, and right ear pain. His runny nose has clear mucus and started when his cough got worse. He reports frequent cold and runny nose. He also mentioned that he had frequent ear infection as a child and had pneumonia in the past year. His throat soreness is rated as a 2/10 on the pain scale and his right ear pain which started yesterday rated as 3/10 on the pain scale. He denies being around any sick child or person. He denies fever, headache, dizziness, shortness of breath, or difficulties breathing, nosebleed, trouble swallowing, sputum or phlegm, chest pain, aggravation of cough with activity.

Medication: Purple cough medicine this morning that helped a little, but the cough returned. No other medication

PMH: No surgeries or hospitalizations. Reported that his cough always comes around his nose usually gets runny but “never this bad”. Had ear infection as a child. No asthma reported or use of inhaler. Had pneumonia last year and was treated at urgent care.

Immunizations: Current and up to date but has not had the flu vaccine in the last 12 months.

· Hepatitis B series completed at 6 months.

· Hepatitis A series completed at 15 months

· Pneumococcal vaccine at 15 months

· DTAP at 6 years old

· MMR at 6 YEARS

· Varicella vaccine at 6 years

· Polio Vaccine at 6 years

Type your narrative-style documentation for each section of the assignment into the corresponding dialogue boxes below. When you are ready to submit your documentatio, ‘Save As’ with this title format: “[LastName_FirstName] Shadow Health Documentation Template – FE_Cough – NURS 6512”

Medication: Over the counter medication (Purple cough medicine) that helped a little, but the cough returned. He reported a daily children gummy vitamin. No other medication reported.

Social History: Danny is in the third grade and was out of school for two weeks last year because of pneumonia. He lives with Mother, Father, grandmother, grandmother cares for child while parents are working. He is the only child and reported he feels safe at home. He does not really play sports but does play video games with his friend Tony. Primarily speaks English in the house but sometimes Spanish.

Family History: Father is a smoker, and occasionally smoke in the house, hypertension, hypercholesterolemia, Asthma as a child. Mother has type 2 diabetes, hypertension, Obesity, hypercholesterolemia and spinal stenosis. Maternal grandmother has DM2 and hypertension. Maternal grandfather is a smoker, eczema. Paternal grandmother died at age 52 of a car accident. No known history of paternal grandfather.

ROS: Denies fever, reports feeling tired, denies headache, dizziness, vision problems, trouble hearing, recent nosebleed. He also denies difficulty swallowing, breathing.

Objective

Vital signs: B/P 120/91; Pulse 100; Temperature 37.2C, Respiration 28; 02 sat 96%; weight 90lbs; Height 4’2”

Spirometry: FVC: 3.91 L FEV1 3.15 L (FEV1/FVC: 80.5%) Increase respiration at 28 Mild tachycardia is 100 bpm Appears fatigued but appear stable, breath sounds clear to auscultation able to speak full sentences.

HEENT: Head is symmetric and proportioned to body size; Eyes – sclera white, conjunctiva moist and pink, no discharge but appears dull; Ear – right ear is erythema, with the tympanic membrane red and inflamed compared to the left ear; Nose – clear discharge; throat – redness and cobblestoning in the back of the throat. Right cervical lymph nodes enlarged with tenderness.

Cardiovascular: S1, S2, present with no extra sound or murmur, gallops, or rubs.

Respiratory: Normal breath sounds and cleared in all areas on auscultation, respiration rate is increased with no acute distress, speaks in full sentences, no adventitious sounds. Bronchophony is negative. Chest wall is resonant to percussion.

Assessment

Assessment:

1.) Common cold

2.) Strep throat

3.) Rhinitis

4.) Asthma

5.) Allergies due to the abnormal findings affecting the upper respiratory tract, right ear and Lymphatic nodes.

Plan: Perform a strep culture to rule out strep throat. Check with the mother regarding flu shot. Education on mouth covering when coughing and frequent hand washing to avoid spreading germs. Perform lung function test to rule out asthma, and allergy test to rule out allergies. Continue to encourage fluids and avoid dairy products which can make the cough worse. Educate parents on second-hand smoking and to avoid smoking near Danny. Teach Danny to report symptoms to parents if there is no improvement. Ask his mother the name of the cough medication Danny took and document the frequency and the dose. Provide Danny with medication to decrease frequency and help with fatigue from not sleeping, medication for the runny nose, and provide pain relief for throat soreness and right ear pain. Educate family to return in a few days if symptoms is not relieve or get worse.

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Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) 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 AA 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: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve 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 OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs 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 Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing 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: etc.

Diagnostic results: Include any labs, 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 should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

P.   

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

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