Create a scenario using the attched table and work up a final diagnosis for a pediatric patient seen in the clinic. Your final diagnosis should be allergic rhinitis
Name: Pt. Encounter Number:
Date: Age: Sex:
Reason given by the patient for seeking medical care in quotes
Describe the course of the patients illness including when it began character of symptoms location where the symptoms began aggravating or alleviating factors pertinent positives and negatives other related diseases past illnesses and surgeries or past diagnostic testing related to the present illness.
Medications: (List with reason for med )
Chronic Illnesses/Major traumas
Have you ever been told that you have diabetes HTN peptic ulcer disease asthma lung disease heart disease cancer TB thyroid problems kidney problems or psychiatric diagnosis?
Does your mother father or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with: lung disease heart disease HTN cancer TB DM or kidney disease?
Education level occupational history current living situation/partner/marital status substance use/abuse ETOH tobacco and marijuana. Safety status
Assessment specific to disease system-
o Include at least three differential diagnosis
o Final diagnosis
? Evidence for final diagnosis should be documented in your Subjective and Objective exams.
PLAN including education
? Further testing
? Nonmedication treatments