Focused note

Overview

• 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. 13 yo male seen in clinic with dad with c/f swollen lymph nodes, sore throat x 2 days and coughing up small white lumps this morning. denies fever, rapid strep test negative.
• Objective: What observations did you make during the physical assessment? Assessment with swollen lymph node on right side of neck. THROAT: small whitish/ yellowish appearing lumps visible on tonsils. 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