To prepare: Review the Focused Note Checklist provided in this week’s Learning R

To prepare:
Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will develop your Focused Note for this week’s Assignment.
Use the Focused SOAP Note Template and the example found in the Learning Resources for this week to complete this Assignment.
Select an adolescent patient that you examined during the last 3 weeks. With this patient in mind, address the following in a Focused Note.
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?
This is the patient that I examined. I have attached a sample form to use. I also have the diagnoses already it just needs articles pertaining to the diagnoses only.
patient Initial: US Age 16-year gender female race AA
CC: Well child check
HPI: The patient is a 16y old female who came in today for a well-child visit. The patient does live with her parents. she endorses having some migraine periodically. Endorse exercising by participation in sports activities and denies any chest pain on exertion. No history of a sports injury or concussion. Denies smoking, alcohol use, and recreational drugs. Endorse having her menses regularly every 4 weeks and lasting 4-5 days. She denies being sexually active. she reports sleeping well with no issues. No recent significant weight loss or gain. Does have good eating habits, a well-balanced diet, and adequate fluid. Personal social: appropriate behavior, hobbies/sports, best friend, group activities, appropriate interaction, no gang involvement, no risky behavior identified. The child does have a good support system and extended family involved, including father, involve, and grandparents. Both parents work. No fire gun at home.
The patient gets along well, has no stress, has good concentration, has no abrupt mood changes, has a good level of energy, good motivation, no feeling of guilt or isolation, does not carry a weapon, is not depressed, has no thought or history of violence. NKDA. PMHX Acute bronchitis, Dysmenorhea, Migraine without aura and status migrainosus, notintactable
no current medication
Objective: T 97.8 WT 133LB 12OZ HT 5FT 3 IN BP 127/76 P 76
General appearance: alert, Active well nourished
Skin: normal, no skin lesions, no tattoos, no scars
Head: normocephalic, atraumatic
Eyes: red reflex present bilaterally, extraocular movements intact, no eye discharge
Ears: Bilateral TM normal color, canals normal
Nose: nare patent and clear, mucosa normal
Oral cavity/throat: moist mucus membranes, no lesions, throat normal, palate normal
neck: supple, no lymphadenopathy, thyroid normal
chest: normal contour good expansion, symmetric
Heart: regular rate and rhythm, normal S1S2, no murmurs, normal peripheral pulses
Lungs: Clear to auscultation, equal breath sounds bilaterally
Abdomen: soft, non-tender, no masses, normal bowel movement
Genitalia: normal external genitalia
Extremities/back: hip exam normal with no clicks, normal exam of the spine, moving all extremities equally.
Neurologic exam: normal tone and motor development, no abnormal reflexes
Assessment: Encounter for routine child health examination without abnormal findings Z00.129
Immunization – Z23
Migraine without aura and without status migrainosus, not intractable G43.009
Plan: Start Rizatriptan Benzonate Tablet, 5 MG, 1 Tablet, twice a day, 10 days, 20 tablet 1 refills
Hearing screen done and normal bilaterally. Vision screening done and 20/20
Menveo 0.5 ml IM given
Meningococcal B 0.5 ml IM given
Lab: Quantiferon-TB Gold plus, CPM, CBC With diferential/ platelet, Lipid panel done
Patient counsel on healthy food choices, regular exercises. counseled on self breast exam. oral hygiene and dental appointment. safe sex , sexual transmitted diseases education, use of condoms, birth control. skin/UV protection. smoke exposure. Drivers education discussed driving under the influence of alcohol/ drugs, obeying driving rules. RTC in a year or as needed.
IMMUNIZATION: Dtap 11/30/2010 . Gardasil 9 01/22/2021 and 07/22/2020 Hep A 01/19/2011 IPV 11/30/2010 Meningococcal 03/08/2023 Menveo 03/03/2023 and 07/23/2019 MMR 11/30/2010
Tdap- Adacel or Boostrix 07/23/2019 Varicella 11/30/2010