Patient initial: VJ
Age: 16
Gender: Male
Race: AA
Diagnoses:
CC: Allergies
HPI: The patient is a 16-year-old AA male brought to the clinic by his mom for an allergic reaction. Per the patient, this has been happening on and off. He noted some rash on his legs and arms. he stated that the affected areas was red and itchy. Denies any other symptoms or concerns at this time. Per mom, they have not used anything on it. Past medical history of Asthma, unspecified, with acute exacerbation, Allergic Rhinitis, cause unspecified. The patient lives with both parents. No emergency visit since he was last seen. Good exercise tolerance, regular sports participation, no chest pain on exertion, no history of a sports injury or concussion. He does not smoke, not drinks alcohol, and never uses recreational drugs. He is not sexually active. Sleep well throughout the night. Body image satisfied, no recent significant weight loss or gain. Diet, good eating habits, a well-balanced diet, a good appetite, and adequate fluid. Normal bowel movement with normal consistency. The patient temperament gets along well, has no stresses, has good concentration, no abrupt mood changes, has a good level of energy, good motivation, no feelings of guilt or isolation, does to carry a weapon, is not depressed, has no suicidal thought, no thought of the history of violence. The patient does have a summer job. Good peer interaction, no gang involvement, no risky behavior patterns identified
Objective: VS T 98.3 WT
General appearance: No acute distress, well nourished and hydrated.
Skin: Red Papular Rash on legs and arm
Head: Normocephalic, atraumatic.
Eyes: red reflex present bilaterally, extraocular movements intact, no eye discharge
Ears: bilateral TM normal color, canal normal
Nose: Nares patent and clear
Oral cavity/throat: No lesions
neck: No Lymphadenopathy, supple
Chest: Clear to auscultation, normal shape, and expansion
Heart: No murmurs, regular rate, and rhythm
Lungs: Clear to auscultation
Abdomen: soft, non-tender/nondirected, bowel sounds present.
Genitalia: normal
Extremities/back: normal range of motion
Neurologic exam: Normal cranial nerves II-XII sensory and motor within normal limits, DTR 2 plus, normal sensation and strength, normal strength, tone, and reflexes
Assessment: Contact Dermatitis primary. Eczema, urticaria
Plan: Start Diphenhydramine HCL Capsule, 25 mg, 1 capsule at bedtime as needed, orally, twice a day, 5 days, 10 capsule
Start Triamcinolone acetonide cream, 0.025% 1 application to the affected area, externally, three times a day, 5 days.
Treatment is the control of symptoms, as there is no cure. Initial treatment includes
Maneuvers to keep the skin moist such as
Shorter lukewarm baths or showers
Use hypoallergic or mild unscented soaps and laundry products
Topical moisturizer creams daily
Keep the kid well hydrated and ensure adequate skin moisture
Wearing cotton (which allows more air circulation) can be helpful, as wool and polyester may be too harsh, warm or irritating
Minimized allergens such as pollen, mold, tobacco smoke, pet dander
To prevent infections, keep nails clipped short to minimize excoriations and create portals for skin infection. Light white gloves can be worn when sleeping to minimize skin trauma.
immunization: Meningococal B: 0.5 ML IM 6/29/ 2022
Menveo: 0.5 ML IM 6/29/2022 8/22/2017
DTaP 11/27/2005, 12/27/2006 10/22/2009 03/24/ 2010
Varicella 10/18/ 2009 04/14/2008
TdaP 08/22/2017
Prevnar 7 10/07/2009 01/13/2010
MMR 10/14/2009 12/10/2010
IPV 11/27/2005 12/27/2005 01/27/ 2006 02/10/ 2010
Hib: 02/16/2007 03/01/2007 04/01/ 2007 03/13/ 2008
HEP B: 10/27/ 2005 12/27/ 2005 01/27/ 2006
Gardasil 9: 08/22/ 2017 09/27/ 2019
To prepare:
Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will develop your Focused Note for this week’s Assignment.
Use the Focused SOAP Note Template and the example found in the Learning Resources for this week to complete this Assignment.
Select an adolescent patient that you examined during the last 3 weeks. With this patient in mind, address the following in a Focused Note.
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?
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?
To prepare:
Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will develop your Focused Note for this week’s Assignment.
Use the Focused SOAP Note Template and the example found in the Learning Resources for this week to complete this Assignment.
Select an adolescent patient that you examined during the last 3 weeks. With this patient in mind, address the following in a Focused Note.
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?
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?
Focused SOAP Note:
Patient Initials: VJ
Age: 16
Gender: Male
Race: AA
Subjective:
The patient presents with a complaint of allergies, reporting a red and itchy rash on his legs and arms that has been occurring on and off. The patient denies any other symptoms or concerns at this time. The mother confirms the patient’s report and states that they have not used anything on it. The patient has a past medical history of asthma and allergic rhinitis, cause unspecified.
Objective:
The patient appears well nourished and hydrated with no acute distress. A red papular rash is observed on the patient’s legs and arms. The head is normocephalic and atraumatic, and the extraocular movements are intact with no eye discharge. The bilateral TM is of normal color and the canal is normal. The nares are patent and clear, and there are no lesions in the oral cavity/throat. The neck is supple with no lymphadenopathy. Clear to auscultation is observed in the chest, and the heart rate is regular with no murmurs. Clear to auscultation is also observed in the lungs. The abdomen is soft and non-tender/nondirected with bowel sounds present. Normal range of motion is observed in the extremities/back. A neurological exam reveals normal cranial nerves II-XII sensory and motor within normal limits, DTR 2 plus, normal sensation and strength, and normal strength, tone, and reflexes.
Assessment:
The patient is assessed with contact dermatitis primary, eczema, and urticaria.
Plan:
To control the symptoms, treatment will include:
Diphenhydramine HCL Capsule, 25 mg, 1 capsule at bedtime as needed, orally, twice a day, 5 days, 10 capsule
Triamcinolone acetonide cream, 0.025% 1 application to the affected area, externally, three times a day, 5 days.
To keep the skin moist, the following measures will be taken:
Shorter lukewarm baths or showers
Use hypoallergic or mild unscented soaps and laundry products
Topical moisturizer creams daily
Keep the kid well hydrated and ensure adequate skin moisture
Wear cotton (which allows more air circulation)
Minimize allergens such as pollen, mold, tobacco smoke, pet dander
Keep nails clipped short to minimize excoriations and create portals for skin infection
Wear light white gloves when sleeping to minimize skin trauma.
Immunization:
Meningococcal B: 0.5 ML IM 6/29/ 2022
Menveo: 0.5 ML IM 6/29/2022 8/22/2017
DTaP 11/27/2005, 12/27/2006 10/22/2009 03/24/ 2010
Varicella 10/18/ 2009 04/14/2008
TdaP 08/22/2017
Prevnar 7 10/07/2009 01/13/2010
MMR 10/14/2009 12/10/2010
IPV 11/27/2005 12/27/2005 01/27/ 2006 02/10/ 2010
Hib: 02/16/2007 03/01/2007 04/01/ 2007 03/13/ 2008
HEP B: 10/27/ 2005 12/
