Assignment 2: Episodic Visit: Adolescent Focused Note (Ages 13-19)

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Focused Notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused Notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

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.

Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using SAFE ASSIGN.

Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

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 evaluation?

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Episodic Visit: Adolescent Focused Note (Ages 13-19) Sample

Patient Information:

Age: 14yrs

Sex: Female

Race: African American

Informant: Mother and patient

Subjective

CC (chief complaint): Medication refill and allergic rhinitis

HPI: The patient is a 14-year-old female accompany by her mother with a PMHx of allergic rhinitis who presents for follow up. She continues occasional shortness of breath. At those times she will use her inhaler which helps; she states she uses it a few times per day.  She denies any wheezing or coughing. She does admit she has been sneezing a lot. She denies sinus pain or pressure, ear pain. She is scheduled for an appointment with the Allergy and Asthma Clinics of Ohio today.

Her mother states she has tried to call the psychiatrist office and they have not gotten back to her. She plans to go there in person to make an appointment for her today. She denies fever, chills, vision changes, chest pain, diaphoresis, lightheadedness, dizziness, nausea, vomiting, and problems with bladder or bowel movements, numbness, tingling, and weakness. Has abdominal pain prior to periods or with certain foods like cinnamon or garlic. She admits to feeling down several days of the week. She denies SI/HI. Also admits to feeling nervous and anxious. Has fatigue and occasional HAs, palpitations.

Current Medications:

• fluoxetine 10 mg capsule
• 1 capsule by mouth daily
• Zyrtec 10 mg tablet
• 1 tablet by mouth daily
• Flonase Allergy Relief 50 mcg/actuation nasal spray,suspension
• 2 squirt in the nostrils daily
• Vitamin D2 1,250 mcg (50,000 unit) capsule
• 1 capsule by mouth weekly
• doxycycline hyclate 100 mg tablet
• 1 tablet by mouth daily
• clindamycin 1 % lotion
• apply on the skin twice a day; APPLY SMALL AMOUNT TO FACE, 2 TIMES DAILY 10/09/2020
• benzoyl peroxide 5 % topical cleanser
• apply on the skin twice a day; To wash Face BID

Allergies: Mold

PMHx: the patient is up to date on immunizations and has been diagnosed with the following

• Acne Vulgaris: L700
• Atopic Dermatitis, Unspecified: L209
• Dyspnea, Unspecified: R0600
• Other Fatigue: R5383
• Allergic Rhinitis, Unspecified: J309
• Body Mass Index Pediatric, > Or Equal To 95% For Age: Z6854
• Major Depressive Disorder, Single Episode, Moderate: F321
• Encounter For Screening For Depression: Z1331
• Encounter For Examination For Adolescent Development State

Soc & Substance Hx: patient denies illicit drug and alcohol use.

Fam Hx: she lives with her mom who is a single parent. Pt’s mom came from the West part of African Sierra Leone and English is her second language. Her mother works as a care provider in a skilled nursing facility. Her mother is alive and currently lives with her. Her father is also alive but lives in Africa. His first brother   is alive and has a history of schizophrenia. She however denies familial history of cancers, hypertension, or cardiovascular diseases.

ROS:

General: she reports weight gain and fatigue but denied chills, fever, weakness, and decline in Health.

HEENT: Eyes: she uses eyeglasses; she denied blurry vision, double vision, pain with light, eye pain, and redness. ENT: she denied discharge, frequent colds and sore throats, hay fever, infections, nasal obstruction, nosebleeds and sinus infections. Mouth: she denied voice changes, change in dentition, and tongue burning.  Ears: she denied ringing in the ears, pain, and infections.

Skin: patient reports dryness and skin color change. She denied itching.

Breast: patient denied lumps, tenderness, and pain.

Cardiovascular: the patient reported shortness of breath while asleep. she denied chest pain and leg pain while walking, swelling of legs, and high blood pressure.

Respiratory: the patient reported shortness of Breath. She denied asthma and cough.

Gastrointestinal: the patient denied abdominal pain, decreased appetite, excessive thirst, nausea, vomiting, constipation, and diarrhea.

Genitourinary: the patient denied burning, foul-smelling urine odor, urgency, pain on urination, frequency, incontinence, urine discoloration, and retention.

Neurological:  the patient denied tingling, numbness, headaches, dizziness, blackouts, fainting, and loss of consciousness, paralysis, burning, head injury, memory loss, speech disorders, strokes, tremors, and unsteady gait.

Musculoskeletal: the patient denied muscle cramps, restricted motion, back problems, joint pain, arthritis, deformities, gout, joint stiffness, muscle stiffness paralysis, and weakness.

Hematologic: the patient denied anemia, bleeding easily, blood clots, easy bruisability, lumps, radiation exposure, swollen glands, and transfusion reaction.

Psychiatric: the patient reported excess stress, nervousness, and depression. She however denied mood changes, hallucinations, disorientation, behavioral change, disturbing thoughts, memory Loss, and psychiatric disorders.

Endocrinologic: the patient reported fatigue and weight gain. She denied cold intolerance, neck pain, increased thirst, and excessive urination.

Allergies: the patient denied anemia, bleeding easily, blood clots, easy bruisability, lumps, radiation exposure, swollen glands, and transfusion reaction.

Objective

Physical exam:

General: the patient is an African American female who appears the stated age and is generally healthy. She has clean clothing. The hair, nails, teeth and skin are clean and well groomed.

Neurologic: she is awake, alert, well developed, well-nourished and groomed, and in no acute distress. ​

The skull is normocephalic, atraumatic and without masses. The patient’s facial expression and facial contours are normal. There is no facial droop.

Respiratory: The patient is relaxed and breathes without effort. She is not cyanotic and does not use the accessory muscles of respiration. There are no crackles, wheezes, rhonchi, stridor or pleural rubs.

Cardiovascular: on palpating the chest wall, there are no heaves, lifts, or thrills. The pulse rate is normal, the rhythm is regular, S1 and S2 are normal, there are no murmurs, no gallops, and there are no rubs.

Musculoskeletal: Upon inspection, the alignment of the major joints and spine is symmetrical. There are no deformities or misalignment of bones. There are no ecchymosis, erythema, lacerations, subcutaneous nodules, or signs of muscle atrophy. Upon palpation there is no edema, effusions, temperature changes, tenderness or crepitus. The boney landmarks are normal and there is physiologic continuity of the anatomic structures. Range of motion testing reveals no restriction or instability related to ligamentous laxity. Muscle strength testing is 5/5 in all major muscle groups. Special testing of the joints for range of motion, nerve compression, and joint contracture is within normal limits.  Upon inspection, the alignment of the major joints and spine is symmetrical. There are no deformities or misalignment of bones. There is no ecchymosis, erythema, lacerations, subcutaneous nodules, or signs of muscle atrophy. Upon palpation there is no edema, effusions, temperature changes, tenderness or crepitus. The boney landmarks are normal and there is physiologic continuity of the anatomic structures. Range of motion testing reveals no restriction or instability related to ligamentous laxity. Muscle strength testing is 5/5 in all major muscle groups. Special testing of the joints for range of motion, nerve compression, and joint contracture is within normal limits.

Dermatologic: Acne and Rosacea

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Diagnostic Tests-

1. Lipid panel E78.5-pending
2. CMP R79.89-pending
3. CBC with Differentials R68.89-pending
4. A1c R73.09-pending
5. Thyroid Panel with TSH R94.6-pending
6. Vitamin D E55.9-pending
7. Vitamin B12Ferritin-pending
8. Folate-pending
9. Iron

Assessment

Differential Diagnoses

• Allergic Rhinitis (J30.9)-allergic rhinitis occurs when the nasal membranes become inflamed. Patients may present with an allergen history and symptoms of nasal congestion, shortness of breath (SOB) rhinorrhea sneezing, and   nasal itching. On physical exam, the clinician may note thin watery nasal secretions, deviation of the nasal septum and a nasal crease (Wheatley & Togias, 2015).  Ear exam may reveal an abnormal flexibility and retraction of the tympanic membrane, excess production of tears, swelling and injection of the conjunctivae.
• Major Depressive Disorder, Mild (F33.0)-according to the DSM-V criteria, patients with mild major depressive disorder experience persistent feelings of sadness and loss of interest in activities that were previously interesting or enjoyable. Additional symptoms to meet this diagnostic criteria that this patient presented with  include  sudden  weight gain or weight loss, difficulty falling asleep , restlessness, lack of energy/fatigue/feeling unusually tired (Otte et al., 2016).
• Fatigue (R53.83)-fatigue is a state of unresolved exhaustion that does not resolve with adequate rest. Patients may report having decreased energy or a persistent state of tiredness which hinder the ability to perform ADLs and inability to concentrate, leading to emotional, physical, and mental distress and deficiencies of vitamins (Kuppuswamy, 2017). In most cases, fatigue is usually a symptom of an underlying physical or psychological condition. However, a formal diagnosis is based on a patient’s history, ROS and clinical examination. However, additional laboratory investigations as ordered can help to identify its causative cardiovascular, hematologic, or metabolic causes.

Plan

1. Educated and suggested patient to go to counseling
2. Referral made to asthma specialist and psychiatry
3. Sample of Qvar given in office, instructed patient to use 2 puffs per day
4. Prescription sent for Albuterol inhaler
5. Follow up in 2 Weeks

Reflection 

What I learned from this experience?

This clinical experience was the most interesting since I was able to   provide this patient with holistic care with referrals to the most appropriate medical specialists. I also found it interesting that although the mother worked as a care provider in a skilled nursing facility, she let me attend to her daughter professionally including educating them about allergic rhinitis. This experience taught me that, irrespective of the professional background of a patient or the in-depth knowledge they possess on disease processes, clinicians should not make assumptions that the patient knows what to do. Instead, every patient must be handled separately based on their needs. With regards to history taking, physical exam, assessment, and the management of this patient, there is nothing that I would do differently.

References

Kuppuswamy, A. (2017). The fatigue conundrum. Brain, 140(8), 2240-2245.

Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., … & Schatzberg, A. F. (2016). Major depressive disorder. Nature reviews Disease primers, 2(1), 1-20.

Wheatley, L. M., & Togias, A. (2015). Allergic rhinitis. New England Journal of Medicine, 372(5), 456-463.