Noah Caputo Dermatology school age sick visit shadow health
Documentation / Electronic Health Record
Flowsheets
My Provider Notes
Diagnostic Notes
Vitals
Vitals – Current Visit
Height – 122 cm
Weight – 20.8 kg
BMI – 14.3
Temperature (<38° C) – 36.2° C
Heart Rate (60-100) – 78
Respiratory Rate (12-20) – 22
Blood Pressure – 100/68
Documentation / Electronic Health Record
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My Provider Notes
Student Documentation Model Documentation
Subjective
Noah Caputo, a 7-year-old male, is brought to the clinic by his uncle due to complaints of an itchy rash on his feet and legs. The patient reports that the rash began last weekend and has been progressively itchy. He denies experiencing any pain, bleeding, or pus related to the dermatological issue observed during this school-age sick visit.
Reason for Seeking Care: Noah presents with a chief complaint of a rash on his lower legs.
History of Present Illness: Noah Caputo, a 7-year-old male, is accompanied by his uncle, a non-guardian caretaker, reporting a pruritic rash on his lower legs noticed one day ago. The rash is described as red bumps on both lower legs. There is no reported exposure to pets at home, but the patient has been in contact with a neighbor’s dog. Scratching and showering exacerbate the itching. No topical treatments have been attempted. The uncle applied a cold compress to alleviate the itch, and children’s diphenhydramine provided relief. Noah is not currently on any medications, has no known medication allergies, and has no current medical issues, hospitalizations, or surgeries. Socially, he enjoys school but reports being bullied and struggling with allegations of theft. He lives with his parents, spends nights alone at home, and faces challenges in preparing meals for himself. The caretaker is uncertain about Noah’s immunization status. There is no known family history of skin conditions.
Case Study- 4-year-old African American male living in a rural community
Review of Systems Constitutional: Noah denies fever, chills, fatigue, or pain during this dermatology school-age sick visit documented in Shadow Health.
Vitals
| Vitals | Current Visit |
|---|---|
| Height | 122 cm |
| Weight | 20.8 kg |
| BMI | 14.3 |
| Temp (<38° C) | 36.2° C |
| HR (60-100) | 78 |
| RR (12-20) | 22 |
| BP | 100/68 |
Documentation / Electronic Health Record
My Provider Notes
Tina Jones Comprehensive Assessment shadow health Transcript
| Student Documentation | Model Documentation |
|---|---|
SubjectiveNoah Caputo is a 7-year-old male who is brought to the clinic by his uncle with complaints of an itchy rash in his feet and legs. The patient reports that the rash began last weekend when it started feeling itchy. Denies any pain, bleeding or pus dermatology school age sick visit shadow health documentation. |
Reason for seeking care: “Rash on lower legs.” History of Present Illness: Noah Caputo is a 7 year old male here today accompanied by his uncle who is a non-guardian caretaker with a pruritic rash on his lower legs that his uncle noticed one day ago. Describes rash as red bumps on both lower legs. Does not have any exposure to pets at home, but has had exposure to a neighbor’s dog. States scratching at the bumps and showering make it itch worse. They have not tried any topical treatments for the itching. His uncle did try putting a cold compress on his legs to help relieve the itch. His uncle did give him children’s diphenhydramine with good relief. Medications: No current medications. Allergies: No known medication allergies. Medical History: No current medical issues. Denies any prior hospitalizations or surgeries. Social History: Noah reports enjoying school and denies getting in trouble at school. However, he does report being bullied. Caretaker reports hearing that Noah has been stealing at his school. Noah lives with his parents. Reports being home alone at night and struggling to prepare meals for himself. Health Maintenance: Caretaker is unsure if Noah is up to date on his immunizations. Family History: No known family history of skin conditions. Review of Systems Constitutional: Denies fever, chills, fatigue, or pain dermatology school age sick visit shadow health documentation Dont wait until the last minute.Provide your requirements and let our native nursing writers deliver your assignments ASAP. |