Adherence Issues with Medications Essay
Patient Demographics
Age:
9 months
Race:
Hispanic
Gender:
Female
pt has father, mother, two sisters and just moved to United States from Mexico
Type of Decision-Making: Low complexity
Student Participation: Primary (>50%) Adherence Issues with Medications Essay
Reason for Visit: Episodic
Chief Complaint: vomiting and diarrhea
Encounter #: 1
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-10 Diagnosis Codes
#1 – R11.2 – NAUSEA WITH VOMITING, UNSPECIFIED
#2 – K59.1 – FUNCTIONAL DIARRHEA
CPT Billing Codes
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Medications
# OTC Drugs taken regularly:
0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Analgesic/Antipyretic – Acetaminophen combinations Adherence Issues with Medications Essay
GI Agents – Miscellaneous GI
Adherence Issues with Medications:
Clinical Notes
weight 17lb length 27.5 temp 98.6 f Adherence Issues with Medications Essay
pt arrived to clinic with mother and father. mother is Spanish speaking. father speaks English. pt father states the pt has had vomiting and diarrhea for five days. The patient was on a milk from Mexico called Nan. Parents switched formula to Similac advanced and the patient start vomiting and diarrhea as result. pt father states she is able to eat solids but vomits and diarrhea shortly after. Adherence Issues with Medications Essay
instructed parents to stop formula and start the baby with Pedialyte and baby oatmeal for two days. switched the baby formula to total comfort. instructed parents to go to WIC to pick up formula. If symptoms persist or worsen to come back to clinic.
please use this patient as soap note/ episodic case study. Adherence Issues with Medications Essay
