PRAC_6531 Episodic/Focus Note Template

PRAC_6531 Episodic/Focus Note Template

PRAC_6531 Episodic/Focus Note Template

Patient Information:

Initials: G.R, Age: 27 years, Sex: female, Race: African American

S.

CC (chief complaint): “I have pain in my right year and a sore throat.”

HPI: G.R. is a twenty-seven-year-old African American female patient who came to the facility with reports of pain in the right year and severe sore throat. The patient indicates that she started experiencing these symptoms some four and a half days ago, and she is worried that the symptoms have been getting worse progressively. The patient indicates that the throat pain is constant and stabbing, with a rating of 7 on a scale of zero to ten. The pain gets worse when she swallows something. The patient also reports a low-grade fever, mild hoarseness, and difficulty in swallowing in the last three days. The patient denies any history of recent travel, which might have put her at risk of infections.

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Current Medications: The patient is not currently using any medications

Allergies: The patient has no known allergies, either food allergies or medication allergies.

PMHx: The patient was admitted as a teenager after being involved in a road accident. He was also once hospitalized as a child for measles. Her immunizations are all up to date. She reports having a full vaccination for Covid-19. His tetanus immunization is also up to date.

Soc Hx: The patient is a sociable person and likes going on walking trips with friends. She also loves to play soccer and watches movies more often. She denies any tobacco or alcohol use currently, though she reports using alcohol once in her early twenties. The patient also denies using any other substances, such as marijuana or cocaine.

Fam Hx: The patient’s mother is still alive and is living with hyperthyroidism, which she is currently managing. Her father passed on at 80 years old and was living with diabetes and, later, a stroke. The patient’s grandparents both died at the advanced age of above eighty-five years. While the grandmother died of natural causes, the grandfather had a stroke and dementia. The patient has two siblings, a forty-year-old family man and a younger sister who is still in college and lives with their mother. She is currently living with her husband, and they have one child together.

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.

GENERAL:  No weakness, chills, or weight loss. However, there was a mild fever and fatigue.

HEENT: Eyes: No yellow sclerae, double vision, blurred vision, or visual loss. There is no hearing loss, though there is pain in the right ear. No sneezing, congestion, or runny nose. However, there was a severe sore throat.

SKIN: No skin itching, skin rash, or skin pain.

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

RESPIRATORY: No sputum, cough, or breath shortness.

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

GENITOURINARY: No burning on urination, no change in urine color.

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

MUSCULOSKELETAL: No muscle stiffness, joint pain, back pain or muscle pain

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, cold, or heat intolerance. Positive for polyuria or polydipsia.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Vital signs: Temp 101.9F, BP 138/90, HR 88, RR 16, Sp02 99%

Physical exam:

General: The patient is appropriately dressed and well-groomed. He is alert and oriented. The patient cooperates and has no immediate acute distress. However, he looks worried and bothered by his severe sore throat and eye pain.

HEENT: Atraumatic, normal pattern and distribution of hair. Eyes: Sclera white, Conjunctive pink. PERRLA. No drainage or redness was observed. Ears: The right ear canal appears erythematous and swollen, with mild serous discharge. The tympanic membrane is not visible due to swelling. Erythema and swelling of the right tonsil, with purulent exudate. The left tonsil is mildly erythematous. Mild cervical lymphadenopathy on the right side. Nose: No nasal discharge; the septum is midline. Throat: No swelling, severe sore throat.

NECK: No lymphadenopathy, thyromegaly, masses, or tenderness.

Cardiovascular: normal rhythm and rate

PULMONARY: No hemoptysis; lungs are clear. No cough.

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

ABDOMEN: Normal bowel sounds, non-tender and soft

Diagnostic results: Otoscopic examination and tympanometry to assess the ear pain (Binol et al.,2020). A throat culture and rapid strep test to confirm the presence of bacteria

A.

1. Otitis Media: This is a condition when an individual experiences an infection in the middle ear, which then causes inflammation. It may also cause a build-up of fluid behind the eardrum. A patient with otitis media can present with various symptoms, such as slight hearing loss, lack of energy, fever, and, in most cases, earache or ear pain (Gadday et al.,2019). The patient showed most of these symptoms, making it a primary diagnosis and one of the differential diagnoses.
2. Pharyngitis: This is a condition known to cause inflammation of the pharynx. This condition can be caused by viral or bacterial infection. However, in most cases, it is caused by viral infection. Some of the most common symptoms of pharyngitis include fever, chills, body aches, fatigue, cough, headache, runny nose, sneezing, and sore throat (Holm et al.,2022). The patient showed some of these symptoms, making this condition a possible diagnosis.

• Type 2 diabetes mellitus: This is a condition that is known to present with various symptoms such as lack of energy, fatigue, increased thirst, frequent urination, blurry vision, and feet or hands numbness, tingling, or pain (Chen et al.,2019). The patient also showed some of these symptoms. In addition, her family history predisposes her to type 2 diabetes. Hence, this is a possible diagnosis.

This patient’s condition needs treatment for better outcomes. It is also important to have a therapeutic plan for all the conditions. Additional diagnostic studies are needed to help confirm the diagnosis. One of them is throat culture and rapid strep test or the streptococcal antigen test. The other test is the hemoglobin AIC test for diabetes.

In the case of otitis media, the patient needs to use an amoxicillin dosage of 250 mg q12 for five to ten days, pending the streptococcal culture results (Dawit et al.,2021). This dosage can also help in the case of pharyngitis (Holm et al.,2022). However, the patient needs to take over-the-counter analgesics like ibuprofen to help manage the pain and reduce the fever, which the patient has also reported. In the case of type 2 diabetes mellitus, the patient needs to be referred to a specialist to confirm the condition before any meaningful treatment and management strategies can be commenced.

Reflection:  As part of the reflection, I agree with the preceptor’s treatment of the patients since the basic symptoms of sore throat and ear pain were pointing to the indicated diagnoses. This case also offered an opportunity to learn. For example, the fact that pharyngitis can either be caused by viral or bacterial infection; it is important to carry out a comprehensive test to determine the real cause so that the correct medication and treatment can be administered. One thing I could do differently is inquire from the patient if any of her siblings have been diagnosed with diabetes or if she has ever done a hemoglobin AIC test before. It is also important for the patient to get various education points to help her better manage her condition. The ear pain means that she needs appropriate ear care. The patient needs to use an appropriate technique to keep the ear dry (Gadday et al.,2019). The patient should also have enough rest and hydrate appropriately. The patient should also be advised to adhere to the medication plan and complete the antibiotics dose. The patient needs to be educated that in case of any adverse reactions, she needs to stop the medication immediately and seek medical attention. She should also report to the facility in case the symptoms get worse. The patient should come back to the facility after two months for a follow-up on her diabetes diagnosis.

References

Binol, H., Moberly, A. C., Niazi, M. K. K., Essig, G., Shah, J., Elmaraghy, C., … & Gurcan, M. N. (2020, March). Decision fusion on image analysis and tympanometry to detect eardrum abnormalities. In Medical Imaging 2020: Computer-Aided Diagnosis (Vol. 11314, pp. 375-382). SPIE. https://doi.org/10.1117/12.2549394

Chen, J., Zhao, J., Cao, Y., Zhang, G., Chen, Y., Zhong, J., … & Wu, P. (2019). Relationship between alterations of urinary microbiota and cultured negative lower urinary tract symptoms in female type 2 diabetes patients. BMC urology, 19, 1-13. Doi: 10.1186/s12894-019-0506-0

Dawit, G., Mequanent, S., & Makonnen, E. (2021). Efficacy and safety of azithromycin and amoxicillin/clavulanate for otitis media in children: a systematic review and meta-analysis of randomized controlled trials. Annals of Clinical Microbiology and Antimicrobials, 20(1), 28. Doi: 10.1186/s12941-021-00434-x

Gaddey, H. L., Wright, M. T., & Nelson, T. N. (2019). Otitis media: rapid evidence review. American Family Physician, 100(6), 350-356. https://www.aafp.org/pubs/afp/issues/2019/0915/p350.html

Holm, A. E., Llor, C., Bjerrum, L., & Cordoba, G. (2020). Short-vs. Long-course antibiotic treatment for acute streptococcal pharyngitis: systematic review and meta-analysis of randomized controlled trials. Antibiotics, 9(11), 733. https://doi.org/10.3390/antibiotics9110733

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Assignment:

• Subjective: What details did the patient provide regarding her personal and medical history?
• Objective: What observations did you make during the physical assessment?
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. 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, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
• Reflection notes: What would you do differently in a similar patient evaluation?
• The patient Info is below, and any additional info can be made up.

• Category	Item	Value
  Client Information	Site	Office
  	Age	22–64 years
  	Gender	Female
  Visit Information	Student Level of Function	Intense supervision – Level 1
  	Category of Care	Direct Patient Care
  Practice Management	Type of visit/phys. exam	Acute office – 99213
  Diagnosis	1 Otitis Media all types
  	2 DM2
  Student Notes	The patient came in for an acute office visit. The patient complained of a severe soar throat and ear pain. Amoxicillin 250mg q12 for 10 days. The patient will follow up in 2 months for DM2 A1C labs.

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Criteria	Ratings										Pts
Organization of Write-up	30 to >26.0 pts Excellent All information organized in logical sequence; follows acceptable format		26 to >23.0 pts Good Information generally organized in logical sequence; follows acceptable format				23 to >20.0 pts Fair Errors in format; information intermittently organized		20 to >0 pts Poor Errors in format; information disorganized		30 pts
Thoroughness of History	20 to >17.0 pts Excellent Thoroughly documents all pertinent history components for type of note; includes critical as well as supportive information			17 to >15.0 pts Good Documents most pertinent history components; includes critical information			15 to >13.0 pts Fair Fails to document most pertinent history components; Lacks some critical information or rambling in history			13 to >0 pts Poor Minimal history; critical information missing	20 pts
Thoroughness of Physical Exam	10 to >8.0 pts Excellent Thoroughly documents all pertinent examination components for type of note			8 to >7.0 pts Good Documents most pertinent examination components		7 to >6.0 pts Fair Documents some pertinent examination components		6 to >0 pts Poor Physical examination cursory; misses several pertinent components			10 pts
Diagnostic Reasoning	10 to >8.0 pts Excellent	8 to >7.0 pts Good			7 to >6.0 pts Fair			6 to >0 pts Poor			10 pts
	Assessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic tests	Assessment consistent with prior documentation. Clear justification for diagnosis. Notes most secondary problems.			Assessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests			Assessment not consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests

Criteria	Ratings									Pts
Treatment Plan/Patient Education	10 to >8.0 pts Excellent Treatment plan and patient education addresses all issues raised by diagnoses, excellent insight into patient’s needs. Evidence based decisions. Cost effective treatment. Reflection is thoughtful and in depth.		8 to >7.0 pts Good Treatment plan and patient education addresses most issues raised by diagnoses. Reflection is thoughtful and in depth.			7 to >6.0 pts Fair Treatment plan and patient education fail to address most issues raised by diagnoses. … Reflection is brief, vague. and does not discuss anything that would have been done in addition to or differently.			6 to >0 pts Poor Minimal treatment plan and/or patient education addressed … Reflection is absent.	10 pts
Written Expression and FormattingEnglish writing standards: Correct grammar, mechanics, and proper punctuation.	10 to >8.0 pts Excellent Uses correct grammar, spelling, and punctuation with no errors.	8 to >7.0 pts Good Contains a few (1-2) grammar, spelling, and punctuation errors.		7 to >6.0 pts Fair Contains several (3-4) grammar, spelling, and punctuation errors.			6 to >0 pts Poor Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.			10 pts
Written Expression and FormattingThe assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed.	10 to >8.0 pts Excellent Contains parenthetical/in- text citations and at least 3 evidenced based references are listed.	8 to >7.0 pts Good Contains parenthetical/in- text citations and at least 2 evidenced based references are listed			7 to >6.0 pts Fair Contains parenthetical/in- text citations and at least 1 evidenced based reference is listed			6 to >0 pts Poor Contains no parenthetical/in- text citations and 0 evidenced based references listed.		10 pts
Total Points: 100