PRAC 6531 Episodic/Focus Note Template
FT 44 Female, Caucasian
CC “Left heel pain for one month”
HPI: This is a 44-year Caucasian female who presented with left heel pain for one month. She describes the pain as throbbing, She reports that the pain is worse When she first gets up and steps out of bed and she rates the pain 9/10. The pain lessens to 5/10 after being on her feet for 15 minutes and remains 3-4/10 throughout the day. She takes ibuprofen 600 mg daily with some relief She denies trauma or injury. No new shoes or heels. Works as a lunch lady in the cafeteria at a high school and thinks the pain is from being on her feet a lot. Reports pain only when walking. No pain at rest.
Current Medications: Ibuprofen 600 mg daily for pain for one month, Multivitamin 1 tablet daily.
Allergies: No known drug or food allergies
PMHx: Tdap in 2017. No major illnesses or surgeries.
Soc Hx: She works as a lunch lady in the cafeteria at a high school. Never smokes and does not drink alcohol. Lives with her husband and children. Feels safe at home. Denies domestic violence. Reports use seatbelts all the time. Does not text and drive. She does not have any risky hobbies.
Fam Hx: Daughter age 15 with type 1 diabetes, diagnosed at age 11. Son age 13 in good health. Mother deceased at age 70 from bladder cancer. father deceased: diabetes, high cholesterol, MIX2, first MI at age 65. All grandparents are deceased in their 80’s unknown illnesses and medical history. 2 brothers are in good health. 1 brother with diabetes and high cholesterol.
GENERAL: Appears well. Denies fatigue, malaise, fever, chills, night sweats, weakness, and unexplained weight loss.
HEENT: Eyes: Denies vision changes such as sudden vision loss. Clear sclera. Wears glasses. Ears, Nose, and Throat deny the hearing loss, pain or drainage, no nasal congestion, runny nose, or sneezing. No sore throat.
SKIN: warm, dry. No rash or dryness or itching.
CARDIOVASCULAR: Denies chest pain/ chest pressure or any chest discomfort. No irregular heartbeat.no palpitations or lower extremity edema.
RESPIRATORY: Negative for cough, sputum, hemoptysis, wheezing, or SOB.
GASTROINTESTINAL: Negative for poor appetite, dysphagia, nausea, heartburn, or reflux, dyspepsia, abdominal pain, excessive gas or bloating, constipation, diarrhea, and dark or bloody stools.
No dysuria, pelvic pain, hot flashes, or abnormal bleeding. LMP 08/30/
NEUROLOGICAL:: Negative for dizziness, headache, syncope spells, confusion, weakness, numbness, tingling, slurred speech, gait or balance problems, falls, or tremors..
MUSCULOSKELETAL: Negative for arthritis, muscle weakness, and stiffness. No swollen or painful joints and no night cramps.
HEMATOLOGIC: No easy bruising, abnormal bleeding, or anemia.
LYMPHATICS: Negative for enlarged or painful lymph nodes.
PSYCHIATRIC: Negative for sleep, disturbance, anxiety, depression, and suicidal thoughts.
ENDOCRINOLOGIC: Denies Temperature intolerance, denies symptoms of diabetes: polyuria, polydipsia.
VS: 98.0 89 20 131/73 O2sat 100% Weight 159 Lbs.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidence and guidelines).
- Plantar Fasciitis
- Old fracture
.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).
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.
May check also: NURS 6003N 18 Transition to Graduate Study Assignment