Danny Rivera - Focused note PDF

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Format for a Focused Note Necessary Components for the Subjective information: Date of encounter: 5/29/20 Patient Name or initials: DR Informant: 8-year-old Hispanic American male presents as the patient, seems reliable, brought into office by his Abuela Chief Complaint (CC): “been feeling sick. I have been coughing a lot. Feeling kind of tired.” History of present illness (HPI): Patient presents with a cough beginning 5 days ago. Cough reportedly worse at night. Reports fatigue due to cough at night time and not sleeping. Cough is described as productive and “gurgly and watery.” Sputum is clear. Coughs every few minutes and no aggravation of cough with activity. Denies chest pain or difficulty breathing. Reports right ear pain 3/10. Throat pain 2/10. No difficulty swallowing. Admits to rhinorrhea, clear drainage. Denies recent exposure to anyone who was recently ill. No reports of recent fever. Reports that his mother administered cough medicine one morning, with some relief. Allergies: no known drug food or environmental allergies noted. Medications: Daily Multivitamin and PO over the counter cough suppressant (medication name and dose unknown) Past History: No past surgical history or prior hospitalizations. History of Chickenpox at age 6. Treated at an urgent care 1 year ago for pneumonia. Patient acknowledges a history of recurrent ear infections at a younger age. Family History: Mother: Alive - Diabetes, hypercholesterolemia, hypertension, spinal stenosis, obesity. Father: alive – smoker, hypertension, hypercholesterolemia, asthma as a child. Maternal Grandmother: Alive – type two diabetes, Hypertension. Maternal grandfather: Alive –

smoker, eczema. Paternal grandmother: Deceased – car accident age 52. Paternal grandfather: no known history. Personal and Social History: Patient is currently in the 3rd grade, enjoys school and gets good grades. Best Friend is Tony. Does not play sports, but does some physical activity with friends. Patient was out of school 2 weeks during the previous school year during pneumonia. Currently lives with mother and father and grandmother (Abuela) who cares for him while his parents work. Enjoys video games, no animals in the house, denies recent travel. Admits to some smoke exposure when father smokes in the house. Immunizations are up to date; no influenza vaccination noted in this past year. Pertinent Review of systems (ROS): General: admits to increased fatigue, no changes in appetite or activities. Denies fevers or chills, or night sweats. Skin: denies any rashes or skin changes. Head, Ears, Eyes, Nose, Throat (HEENT): Denies headaches. Denies vision changes, diplopia or blurred vision. Right ear pain 3/10. Denies hearing changes, tinnitus or vertigo. Increased rhinorrhea, clear drainage. Throat pain 2/10. Respiratory: no history of asthma. Denies shortness of breath or wheezing. Admits to constant cough beginning 5 days ago, worse at night. Cardiovascular: Denies chest pain, tightness, or palpitations. Gastrointestinal: Denies nausea vomiting diarrhea or constipation. Denies abdominal pain. Reports normal appetite. Neurologic: Denies headache, trauma, dizziness, or changes in mentation. SUBJECTIVE REFLECTION: Reflect on your performance and interactions with the virtual patient. Include three additional questions you would ask the patient or informant and state how that information would assist you in formulating a diagnosis. 1. Have you been around any other sick individuals before you noticed you weren’t feeling well? – this would help note if there was a possibly transmissible illness that he could have picked up through contact with another person. 2. Do you wash your hands often during the day? – would provide the nurse practitioner with some sort of idea on patient’s overall hygiene. 3. Do you share food and drinks with other kids at school? - would give the provider a potential cause of spread of illness. Objective information:

Vital Signs:

T: 37.2 degrees Celsius RR: 28 HR: 100 BP: 120/76 pO2: 96% on room air Height/Weight/BMI: 127 cm 40.8 kg BMI: 25.3 Physical Exam Constitutional/General survey: fatigued appearing young boy, appears stable. Dressed appropriately, pleasant affect, good eye contact throughout visit. Skin: intact, no notable wounds, lesions or rashes. Head: Atraumatic and normocephalic. Eyes: glazed over in appearance. Sclera white, conjunctiva moist and pink. No conjunctival discharge Ears: Right auditory canal and tympanic membrane is erythemic and inflamed. Left auditory canal appears pink and tympanic membrane pearly gray. No visible abnormal findings such as fluid, bulging, perforations, retractions in either ear. Nose: mucus membrane is moist with clear nasal discharge. Thorat: redness and cobblestoning noted in back of throat upon inspection Lymph nodes: Right cervical lymph node enlarged with reported tenderness to palpation. Respiratory: Resp rate increased but in no acute distress. Able to speak in complete sentences. Breath sounds clear bilaterally, no adventitious breath sounds noted, no broncophony noted. Chest wall is resonant to percussion. Expected fremitus noted equally bilaterally. Productive cough with clear sputum. Spirometry: FEV1: 3.15 L, FVC 3.9 L (FEV1/FVC: 80.5%) Cardiovascular: s1 and s2 audible, no murmurs, gallops or rubs. Neurologic: Awake alert and oriented x3, PERRLA, +3 and brisk bilaterally. OBJECTIVE REFLECTION: Reflect on your performance and interactions with the virtual patient. Identify what information is missing from the physical exam or state what additional exam elements you would have included. Some missing information prior to assessment I would have liked to review were his previous chest xrays from when he was diagnosed with pneumonia 1 year ago as well as documentation from urgent care clinic which diagnosed him with pneumonia.

Assessment information: 8 year old hispanic-american male presents to clinic with fatigue, cough, sore throat and right ear pain x 5 days likely related to upper respiratory infection due to onset and presentation symptoms, and lack of fever. Acute Bronchitis unlikely due to clear sputum and no audible adventitious breath sounds during auscultation. Strep throat unlikely due to no fevers, onset of symptoms, no exudate in back of throat. Allergies unlikely due to cough being worse at night time as well as no aggravating or alleviating factors. Asthma unlikely due to no audible wheezing, denies dyspnea, constant cough, and FEV1 Ratio

greater than 80%. Pneumonia unlikely due to lack of fever, lack of adventitious breath sounds, stable vital signs, and presentation of symptoms. Plan:

Diagnosis: Upper Respiratory Infection Diagnostics: CBC to assess WBC, C- xray to rule out Pneumonia due to history, Strep culture to rule out strep throat. Pharmacology: Robitussin 10ml PO every six hours as needed for cough. Education/Counseling: Provide education to family on use of medications. Health Promotion/Anticipatory Guidance: Encourage patient to increase his fluid hydration, encourage rest. Provide patient and family education on signs of worsening symptoms. Should patient develop increased shortness of breath, fever, chills, wheezing, patient to go to nearest emergency room for evaluation. Referrals: referral to allergist to rule out allergies Follow-up: Call to schedule apt if no improvement of symptoms in 48-72 hours. Self-Assessment: In reflection, think about your experience with this case. Based on evidence-based practices, would you have done anything differently in this case? A thorough and focused health history and physical examination was preformed on the patient’s chief complaint to rule out possible causes of symptoms, including upper respiratory infection, pneumonia, strep throat, acute bronchitis, asthma, and allergies. I performed a thorough HEENT and respiratory exam as well as cardiac assessment. With each question of my assessment and step of my exam I felt more confident in ruling out possible diagnoses. The plan developed above reflects his personal chief complaint as well as both subjective and objective findings of my examination and assessment. As the health care provider, I would not do anything different based on evidence - based practice. References:

Bickley, L. S., Szilagyi, P. G., & Hoffman, R. M. (2017). Bates guide to physical examination and history taking. Philadelphia, Pa: Wolters Kluwer. Th o ma sM, Bo ma rP A. Up p e rRe s p i r a t o r yTr a c t I n f e c t i o n. [ Up d a t e d2 0 20Fe b4 ] . I n: St a t Pe a r l s[ I n t e r n e t ] .Tr e a s u r eI s l a n d( FL) :St a t Pe a r l sPu b l i s h i n g ;2 0 2 0 J a n . Av a i l a bl ef r o m: h t t p s : / / www. n c b i . nl m. n i h . g o v / b o o ks / NBK5 3 29 6 1 /...