Reference no: EM133914133
Assignment: Focus Soap Note
Raymond Pinkowski is an 18-year-old who presents to your outpatient clinic with a 3-day history of painful left ear. He has a recent history of swimming in a friend's pond over this past weekend. He is generally in good health, no significant medical history other than seasonal allergies and has ADHD which was diagnosed when he was in middle school. He recently started a part time job at Target but doesn't work enough hours to qualify for any health insurance, he will be paying out of pocket for the visit and any medications.
HPI/PMH: as presented in the case.
Vital signs: BP 118/70 P 84 R 14 T 99.9 oral Pulse ox 98% on room air
Allergies: NKDA
Medications: Tylenol 500mg 1 or 2 PRN. Not taking medications for ADHD since completing his GED 1 year ago.
ROS: Occasional headaches, left ear pain, states it is 8-9/10 today.
PE: Lungs clear, Heart regular rate and rhythm. Right ear shows clear ear canal, TM with normal light reflex, no fluid noted. Left ear canal red, swollen, unable to perform thorough ear exam due to edema and pain. Some greenish discharge noted from Left ear.
Social History: Lives with his mother in an apartment, has one younger sister also at home. Obtained his GED last year. Drinks alcohol on weekends occasionally, smokes marijuana 1 or 2 times a month with friends, no other reported drug use, no use of tobacco or vaping. Drinks 2 -3 energy drinks daily. No history of interaction with law enforcement, no DUI's.
As you review the case and write your SOAP note please review the following questions and incorporate them into the note.
A. What is the likely cause of this issue for Raymond?
B. Write at least 3 differential diagnoses for this issue.
C. Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?
D. Describe in detail the physical exam you would complete for this visit. Specify in your soap note areas of assessment in detail.
E. What are some of the risk factors for individuals to develop this issue?
F. Name the pathogens most likely involved.
G. How would you describe the severity of Raymonds issue - mild, moderate or severe?
H. What treatment options would you prescribe? Explain your plan for diagnostics and primary diagnosis. What would your plan be 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.
I. List the cost of the medication you prescribe for Raymond - you can use sources like Good Rx or others available on the web to review costs in your area. Get the instant assignment help.
J. What other health promotion topics would you review with Raymond at this visit?
K. What social determinants of health (SDOH) are affecting Raymond's care at this time?
L. What CPT code and E&M code would you use for this visit - this can be added to the end of the SOAP note.
M. Discuss your follow up plan and any need for referral for Raymond after this visit, also are there any free clinics in your area - if so list them.