Description
T.B. a 68-year-old African American male presents to the clinic with the complaint of consistent aching lower back pain for several weeks. The patient states the pain does not radiate but occurs in the lower back section. The patient rated the pain as 7/10, rest and pain medication sometimes helped to relieve the pain. The pain is aggravated by sitting longer in one spot, which disrupts her ADLs as he is unable to do a lot of bending down activity.PMH of chronic lower back pain, Hypertension, Anxiety, HLD, Degenerative Disc Disease, Anemia, Gout, and Asthma Social hX: Denies smoking cigarettes or drinking alcohol, The patient lives alone and he is a pastor. Current medication: Oxycodone 10mg Q 6hrs as needed, Losartan 50mg, Aspirin 81mg, and Xanax 0.5mg. Iron 325mg Supplement, Allopurinol 200mg, Bio freeze ointment.vital signs: , BP 132/97, P 60, R 19, T 97.7, Wt. 174 Ibs. You can add your information as you need to complete the case study. use 5 APA references from the last 5 years to support your diagnosis.
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Master of Science in Nursing
PRAC 6531: Primary Care of Adults Across the Lifespan Practicum
Episodic/Focus Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here in the
patient’s own words (e.g., “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 AA 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, Aleve 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 OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a
description of what the allergy is (e.g., angioedema, anaphylaxis). This will help
determine a true reaction vs 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
© 2020 Walden University
1
Master of Science in Nursing
PRAC 6531: Primary Care of Adults Across the Lifespan Practicum
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use
(i.e., previous and current use), any other pertinent data. Always add some health
promo question here (e.g., whether they use seat belts all the time or whether they have
working smoke detectors in the house, living environment, text/cell phone use while
driving, and support system).
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses.
Reason for death of any deceased first degree relatives should be included. Include
parents, grandparents, siblings, and children. Include grandchildren if pertinent.
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.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations
or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain
or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period,
MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
© 2020 Walden University
2
Master of Science in Nursing
PRAC 6531: Primary Care of Adults Across the Lifespan Practicum
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or
polydipsia.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
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 evidence and guidelines).
A.
Primary diagnosis: Your primary or presumptive diagnosis should be at the top of the
list. (one primary diagnosis)
Differential Diagnoses (list a minimum of four 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 preceptor’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 that relate to this case to support your diagnostics and
differential diagnoses. Be sure to use correct APA 7th edition formatting.
© 2020 Walden University
3
Master of Science in Nursing
PRAC 6531: Primary Care of Adults Across the Lifespan Practicum
Episodic/Focus Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here in the
patient’s own words (e.g., “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 AA 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, Aleve 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 OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a
description of what the allergy is (e.g., angioedema, anaphylaxis). This will help
determine a true reaction vs 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
© 2020 Walden University
1
Master of Science in Nursing
PRAC 6531: Primary Care of Adults Across the Lifespan Practicum
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use
(i.e., previous and current use), any other pertinent data. Always add some health
promo question here (e.g., whether they use seat belts all the time or whether they have
working smoke detectors in the house, living environment, text/cell phone use while
driving, and support system).
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses.
Reason for death of any deceased first degree relatives should be included. Include
parents, grandparents, siblings, and children. Include grandchildren if pertinent.
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.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations
or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain
or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period,
MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
© 2020 Walden University
2
Master of Science in Nursing
PRAC 6531: Primary Care of Adults Across the Lifespan Practicum
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or
polydipsia.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
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 evidence and guidelines).
A.
Primary diagnosis: Your primary or presumptive diagnosis should be at the top of the
list. (one primary diagnosis)
Differential Diagnoses (list a minimum of four 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. Your management/plan for the patient must written
and outlined
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 preceptor’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 that relate to this case to support your diagnostics and
differential diagnoses. Be sure to use correct APA 7th edition formatting.
© 2020 Walden University
3
Master of Science in Nursing
© 2020 Walden University
PRAC 6531: Primary Care of Adults Across the Lifespan Practicum
4
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