Episodic/Focus Note Template

 

Patient Information:

JD, Age, 67Sex f, Race caucasian

S.

CC Pain to my bilateral knees

HPI: JD is a 67years old female who present to the clinic for bilateral knee pain rated at 6/10. Patient reports that she sustained a mechanical fall when bring her groceries inside the house 3 day ago. She did not go to the ER , She took Tylenol 650mg and rested her legs which helped for the most part.. however, today, she work up with excruciating pain that she rated at 7/10, she sustained an abrasion to the left knee. Pain is unbearable and swollen. 

 

 

 

Current Medications:

Prilosec 20mg tab orally daikly

Vit d 5000units once a week

Xeralto 20mg every day

Rosvastatin 40mg daily

Zetia 10mg every day

Celebrex 200mg once daily

Olmesartan – amlodipine- HCTZ 40- 10-25 mg once daily .

Omeprazole 20mg cap one tab 30minutes before meals

Atorvastatin Calcim 40mg one tab po daily

T

Allergies: NKDA , NKFA

PMHx: Hypertension, Hypercholesterolemia , mitral regurgitation, AFB.

Surgical HX – None

Social HX Patient is single , has no children, works as a lab technician , denies smoking, recreational drug use, drinks 1 to 2 glasses of alcohol briverages about 2-3 timnes a month.

Family History – Father – decreased – had history of HTN and Diabetes

Mother – Decearsed – Has history of HTN and arthritis.

 

 

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.

O.

Physical exam: 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. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e., General: Head: EENT: etc.).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A.

Differential Diagnoses (list a minimum of three differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

P.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptorâ€s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).

References

You are required to include at least three evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

 

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