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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

Note:

Focused/Episodic Soap note.

To say N/A is not acceptable. 

For ROS and PE,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.

** (MAKE UP) the missing information in the note (some of the information will have to MAKE UP ie meds, hx, parts of the ROS and PE).

 

In the Assessment/Plan, you will document differential diagnoses as per the assignment. 

 MAKE UP INFORMATION IN ORDER TO COMPLETE THE SUBJECTIVE AND OBJECTIVE INFORMTION.

Use Template Below

Week 5               

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 is based on what the patient tells you. cover systems pertinent to CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if need to). To ensureall 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.

 

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
NURS 6512

 

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