Find attached the assignment 

PRAC 6541:
Primary Care of Adolescents and Children

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race


S.

CC (chief complaint): This is a
brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,”
not “bad headache for 3 days.”

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start
every HPI with age, race, and gender (e.g., 34-year-old African American male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.

Allergies:
Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.

PMHx: Include immunization status (note date of
last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.

Soc & Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.

Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx:
Prior surgical procedures.

Mental Hx:
Diagnosis and treat

Bacterial Vaginosis

Zahavah is a 16 years Gender: Female Race: non-Hispanic White Diagnosis: bacterial vaginosis Subjective Data: HJ is a 16-year-old Hispanic female patient who presented to the office with her mother with a two week history of severe irritation and soreness of her vulva. The patient reported of having a two-week history of burning sensation on passing urine without increased urinary frequency. In addition, the patient complained of having a thick, creamy-white vaginal discharge. She had normal and regular menstrual periods. She agreed to having multiple sexual partners for the last one year since breaking up with her high school boyfriend. She denied taking medications in the management of the issue of concern. Objective Data: Vital signs; BP 110/76, HR 78, RR 26, temperature 98, and an oxygen saturation of 99 percent on room air. In general, HJ was a healthy lad who was well oriented to place, time, and person, without obvious distress. HEENT without issues of concern. On respiratory assessment, the patient had a clear and normal lung sounds bilaterally without crackles and wheezes. Cardiovascular assessment showing normal heart sound without murmurs and gallops. Normal bowel sounds on all quadrants on gastrointestinal examination. Patient denied to have a physical examination on the perineal area. Assessment: History of presenting illness indicating a possible bacterial vaginosis. Positive Whiff test indicating bacterial vaginosis. Plan of care: Clindamycin 300 mg orally twice daily for 7 days was prescribed to help in the management of the issues. Patient educated on the need to avoid multiple sexual partners to avoid reoccurrence of the issue as well as possible sexually transmitted diseases.

Answer below QUESTION

· 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?

Note