Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the bridge of his nose to press and rub there.
He says he’s taken Mucinex OTC the past 2 nights to help him breathe while he sleeps.
When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal. Richard is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear.
His tonsils are not enlarged but his throat is mildly erythematous
NB
-Please make up the information needed to do your Focused/Episodic Soap note.
-To say N/A is not acceptable.
-For ROS and PE, you do not have to Review all the systems, only the ones that are related to the CC. Always review and examine the Resp and CV system no matter the complaint.
**You will need to put in (MAKE UP) the missing information in the note (some of the information you will have to MAKE UP ie meds, hx, parts of the ROS and PE). I’m looking to make sure you know what information to include.
In the Assessment/Plan, you will document your differential diagnoses as per the assignment.
-YOU WILL MAKE UP INFORMATION IN ORDER TO COMPLETE THE SUBJECTIVE AND OBJECTIVE INFORMTION.
– Use Template Below.
Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Immunization History:
Significant Family History (Include history of parents, Grandparents, siblings, and children.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. You will only need to cover systems pertinent to your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Psychiatric:
Neurological:
Lymphatics:
OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Physical Exam:
Vital signs: Include vital signs, ht, wt, temperature, and BMI and pulse oximetry
General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.
HEENT:
Respiratory: Always include this in your PE.
Cardiology: Always include the heart in your PE.
Lymphatics:
Psychiatric:
Diagnostics/Labs (Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.)
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled.
