QUESTIONS. (see pictures for the case scenario and the CHART)
1. Create CHART (C-omplaint, H-istory, A-ssessment, R-x - Drugs, T-reatment) documentation for the patient.
2. What is the discharge goal for the patient? Create discharge plan for the patient using METHOD. (M-edications, E-nvironment, T-reatment, H-ealth teaching, O-ut patient referral, D-iet) see photo for reference
Thank you! :)
Extracted text: Discharge Goal: Return to Home (self-care) Return to Home but needs Assistance Transfer to other Level of Institutional Care Referral to Support Community Services' Home Against Medical Advice Discharge Plan Date: M Time: E T H D
Extracted text: A boy aged 12 years presented to the tuberculosis clinic (TB) with a several year history of a chronically productive cough with associated shortness of breath and wheeze. He also reported of lethargy, night sweats and weight loss. He had been screened for TB, with a negative Mantoux test, 5 years previously. Initially, the patient had been managed by his GP who had referred him on to secondary care with suspected asthma. At this point, he was started on a budesonide with formoterol preventer inhaler (Symbicort) and terbutaline sulfate turbohaler (Bricanyl) to variable effect. Owing to his ongoing symptoms, a chest X-ray was performed which revealed bilateral hilar lymphadenopathy, resulting in a referral to the TB clinic. On initial examination at the TB clinic, his chest was clear on auscultation and he had several small submandibular lymph nodes. His height and weight were on the 9th centile for his age. Repeat TB investigations, including Mantoux, T-spot and sputum AFB, were negative. His sputum culture grew Staphylococcus aureus and he was treated for a lower respiratory tract infection with 2 weeks of coamoxiclav (amoxicillin with clavulanic acid). On admission, he was still symptomatic with a chronically productive cough and poor appetite. Further questioning revealed abdominal pain and steatorrhoea. Examination at this point revealed finger clubbing prompting further investigations into an underlying chronic respiratory condition.