Description
T.B. is a 61-year-old African American female
who presented to the clinic with complaints of abdominal pain and cramping,
general body aches, vomiting, and diarrhea for the past 4 days. The patient
states she noticed symptoms developed after eating a bowl of salad. The patient
rates pain as 9/10 but rate pain upon assessment as 6/10 today, Abdomen
non-distended, hyperactive bowel sound noted, tender to touch on palpation. BP
131/ 64, P 98, R 20, T 99.7, stool culture negative for c-diff, and the patient
denies bloody stool. The patient stated she did not take medication for his
symptoms because she has been vomiting everything she takes.PMH of Bronchitis, Hypertension,
Hyperlipidemia, and GERD.Social hx: current smoker and socially drinks
Alcohol.Current medication: Atorvastatin 20mg,
Nifedipine 90mg, Lasix 40mg, Hydralazine 25mg, and Fluticasone 50mcg spray.
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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.
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 four evidence-based peer-reviewed journal articles
or evidence-based guidelines which relate to this case to support your diagnostics and
differential diagnoses. Be sure to use correct APA 7th edition formatting.
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