For this Assignment, you will work with an adolescent patient that you examined during the last 3 weeks and complete a Focused Note Template in which you will gather patient information, relevant diagnostic and treatment
information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc. In this week’s Learning Resources, please refer to the Focused Note resources for guidance on writing Focused Notes.
Assignment
• Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
• Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?How did you decide between different diagnoses? At least three possible diagnoses should be given. List them from most important to least important, and include the ICD-10 code for the diagnosis next to each one. What was your main diagnosis, and why was it that way?
• Plan: What were your plans for diagnostics and primary diagnosis? How did you plan to treat and take care of the patient? Include both drug-based and non-drug-based treatments, alternative therapies, follow-up parameters, and a description of why this treatment and management plan was chosen.
• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
• Reflection notes: What was your “aha” moment? What would you do differently in a similar patient Assessment?
Case: teenager 16 y/o Hispanic girl looking for a dermatological referral to treat acne.
She does not follow any diet (using whole milk and white bread) she does not practice any sport. Denies family history of cardiovascular issues or MI before 65 y/o
Grades A/B in school. Struggling with acne.
Add the rest of the information according to this.
1-Management Plan
Primary Diagnosis Acne vulgaris L70
Rationale: Acne is usually seen in teenagers or relatively young patients (our pt is 16 y/o); the distribution of the eruption follows a topic patron face, upper shoulder, and chest., including different stages like close or open comedones, pustules cyst, nodules or scars. The patient is motivated for her mother to come and get a dermatologist referral.
Differential diagnoses: Fulminans acne, characterized by open comedones located in the same areas with an active infectious process. Rosacea is a common skin condition that causes blushing or flushing and visible blood vessels in the face. Differential diagnoses: Fulminans acne is a type of acne that has open comedones in the same places where an infection is active. Rosacea is a common skin condition that makes blood vessels in the face stand out and makes people blush or flush. It may also cause small bumps that are full of pus. These signs and symptoms may get worse for a few weeks to a few months, then get better for a while. It may also produce small, pus-filled bumps. These signs and symptoms may flare up for weeks to months and then go away for a while.
References:
Greywal T, Zaenglein AL, Baldwin HE, Bhatia N, Chernoff KA, Del Rosso JQ, Eichenfield LF, Levin MH, Leyden JJ, Thiboutot DM, Webster GF, Friedlander SF. (2017).Evidence-based recommendations for the management of acne fulminans and their variants. J Am Acad Dermatol. 2017;77:109–17.
Medications: Benzoyl -peroxide Start with 1 application per day, then gradually increase to 2 or 3 times per day if needed. Hypoallergenic soap on a daily basis.
Additional tests needed: N/R at this visit.
Referrals: N/R at this visit
Follow: Pt was oriented to make an app fallow in 6 weeks to evaluate the disease resolution and the treatment effectivity.
Social Determinants of Health: Pt is insured at this moment with availability to access the ordered medication.
Health Promotion: The patient and mother were educated on acne skin care. Wash the face no more than twice daily using a gentle non-soap facial skin cleanser (eg, Cetaphil, Oil of Olay bar or foaming face wash, or Dove bar) and warm (not hot) water. Do not pick or squeeze pimples because this may worsen acne and cause skin swelling and scarring. It can also cause lesions to become infected. The use of a moisturizer minimizes dryness and skin peeling. Some acne treatments increase the skin’s sensitivity to sunlight (e.g., retinoids and doxycycline). To minimize skin damage from the sun, avoid excessive sun exposure and use a sunscreen with SPF 30 or higher, that is a broad spectrum
The anterior is the extract of the plan of care; please, you need to add more information to the differential diagnosis that I already mentioned.
The document has to be written in APA format.
They ask for 5 (up to date last five years) references.
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: 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, 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 relatives should 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, include what 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:).
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.
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.
