Patient: 10 year old Caucasian male presented to the clinic with complaint of cough, sore throat, stomach ache x 5 days. mother stated no fever however patient stated he felt feverish 2 days a ago. Nauseas and vomiting time 2 last night. Positive strep test today in clinic. expiratory wheezing noted on assessment. Prescriptions for: Albuterol, z-pack, dexamethasone.
Assignment
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?