Exam (elaborations) NR 511 Week 1 SOAP NOTE Case Study 1 Mary 44 YO Female

Exam (elaborations) NR 511 Week 1 SOAP NOTE Case Study 1 Mary 44 YO Female Mary, 44 year old female, Caucasian S: Subjective Chief Complaint (CC): "My right eye is red and was full of goop this morning." History of present illness (HPI): O: Mary woke up this morning with her right eye red and with "goop" in it L: right eye D: right eye drainage and redness started this morning and continues C: includes left eye; red and goopy drainage present upon waking this morning A: states nothing makes it worse R: states nothing makes it better T: No treatment PMI: Denies past illness or injuries. Hospitalized x 2 for childbirth. No surgeries. No information about immunizations. Drinks alcohol socially. Denies tobacco, illicit or prescription drug use. Sleeps between 6- 7 hours a night. No drug allergies. Does not take any prescriptions medication. She does take a daily multivitamin and a B Complex supplement. SOCIAL Mary is a high school graduate and works full-time at a local business in the ordering department. FAMILY Mary lives at home with her husband, Patrick and her children: 4-year-old twin sons; 7-year-old daughter and 10-year-old step-son. Mary's parents, Katie and John, also live in the home. They are retired and help with child care. Mary has two siblings in good health. Patrick is an only child. His parents died of old age in their 70s. Mary's mother has a history of HTN and HLD. Her father has a history of HTN and HLD and has used tobacco since age 10. Patrick and John both smoke, but outside, and not in the house. There are two dogs and a cat in the home as well. Review of Systems (ROS) Constitutional: denies fever and chills NR 511 Week 1 SOAP NOTE Case Study 1 Mary 44 YO Female Eyes: Denies visual loss or vision changes in either eye, denies pain, denies redness or drainage of the left eye, reports redness and drainage of the right eye. Ears, Nose, Mouth Throat: Denies nasal drainage, sneezing, congestion, or pain. Denies loss of hearing, ringing in the ears, pain with swallowing, neck or throat pain or swelling. Cardiovascular: Denies chest pain or palpitations Pulmonary: Denies shortness of breath or difficulty breathing Lymphatic: Denies swelling of the throat, neck or in the axillary lymph nodes O: Objective: PE: Physical exam VS: Ht, 64 inches, Wt. 149, BMI 25.6, BP 126/72, Temp 98.5, Pulse 72 RR 12 Constitutional: 44 year old Caucasian woman, looks younger than her stated age, alert and oriented x 3, use of appropriate words and speech. In no apparent distress, sitting calmly with her young daughter at her side. She is dressed appropriately for the season, and she is neat and clean. Head: Normocephalic head with evenly distributed thick hair. Eyes: Visual acuity tested with patient wearing old pair of corrective glasses-patient usually wears contact lenses. Snellen chart: right is 20/50 and left eye 20/40; 20/30 bilaterally. No ptosis noted, eyes with no lesions or scarring noted. Brows are even and symmetrical. Left eye: no erythema or exudate noted, sclera is white and clear. Right eye with crusting on lashes, thick yellow mucous present at the medical can thus which re-accumulated immediately upon clearing. Conjunctiva red, PERRLA, EOMs intact. No corneal abrasion or involvement noted. Discs flat with sharp margins, Red reflex noted bilaterally, lashes are present bilaterally. Retinal background has even color, no hemorrhages noted. Macula has even color. Ears: Tympanic membranes are pearly gray and intact with light reflex noted. Pinna and tragus nontender bilaterally. Nose: Nares are patent without exudate. Throat: oropharynx moist, no lesions or exudate. Tonsils grade 1 bilaterally. Teeth in are in good state, no chips or cracks, no cavities noted. Neck supple, No lymphadenopathy. Thyroid midline, small and firm, no palpable masses or nodules. Cardiopulmonary: Heart s1 and s2 noted, no murmur. Lungs: Clear to auscultation bilaterally. Effortless respirations. Gastrointestinal: Abdomen is soft, nondistended, nontender, bowel sounds auscultated in all four quadrants. No organomegaly noted. Hematological/lymphatic/immunologic/lab testing: adenovirus rapid screening test negative A: Assessment Diagnosis: Mucopurulent conjunctivitis of the right eye (ICD 10 code H10.0) (MediCode, 2016). Differential diagnosis: Viral conjunctivitis Rationale: Bacterial conjunctivitis is a bacterial infection of the conjunctiva, usually caused by staphylococcus aurea, pneumococcus or streptococcus, which is commonly found on skin. A gonococcal infection should be considered when abundant amounts of purulent discharge that returns quickly upon clearing (Kumar, 2012). The patient has presented with typical crusting of the eyelids, erythema, the lack of lymphadenopathy and a rapid production of mucopurulent drainage evidenced by the re-accumulation upon cleaning (Quinn et al., 2011). Adenovirus rapid screening test: Negative. Other organisms known for causing conjunctival infections are haemophilus, streptococcus, neisseria, and chlamydia, all which can be tested for through scrapings and culture, if adenovirus testing is negative (Cronau, et al., 2010). P: Plan 1. Medications: Prescription: Ceftriaxone 1g IM x one dose: Administered in clinic (Epocrates Athenahealth[Epocrates], 2016, Quinn et al., 2011). 2. Rx: Azithromycin Ophthalmic solution 1% (2.5mL) Sig: Apply 1 drop to affected eye twice a day (8-12 hours apart) x two days; then apply one drop every day x five days. no refills (Epocrates, 2016). The current medication of choice in the treatment of bacterial conjunctivitis with alleged gonococcal etiology is ceftriaxone (Rocephin). Ceftriaxone is a systemic third-generation cephalosporin, like azithromycin (Quinn et al., 2011). It’s recommended that a systemic antibiotic be given in addition to the topical eye drops, if the eye drainage is mucopurulent and fast producing (Quinn et al., 2011). Additional diagnostic tests: Rationale for testing further: Laboratory tests (culture and sensitivity) to classify bacteria and sensitivity to antibiotics are recommended when patient present with copious mucopurulent discharge and a history of wearing contact lenses (Kumar, 2012).Specific findings that prompt further testing includes hyper acute purulent discharge, those who wear contact lenses, as well as anything symptoms that may indicate a more serious conjunctivitis (Cronau, et al., 2010). Gonococcal bacteria, N. gonorrhoeae and Neisseria meningitides are common culprits of abundant eye drainage (Cronau, et al., 2010). Additional Testing: Gram negative and gram positive stain w/direct fluorescent monoclonal antibody staining of smears, Enzyme immuno-assay (Kumar, 2012). 3. Education: Practice of good hand hygiene by washing hand frequently with warm water and soap and vigorous scrubbing, making sure to rinse thoroughly. Patient education regarding correct hand washing can help greatly to break the chain infection transmission (Quinn, et al., 2011). The clinician should reiterate the importance of hand washing by patients and family members; the use separate linens, towels, washcloths, make-up, etc., as well as no contact with infected persons (Quinn, et al., 2011). Proper hand and medical equipment washing, following patient contact, can help to decrease the spread of this very contagious virus (Quinn, et al., 2011). Patients and their sexual partners should be referred to an appropriate medical specialist, if they are infected with an STD. (Kumar, 2012). 4. Referrals: Mary should be referred to an ophthalmologist. Bacterial conjunctivitis with reaccumulating, copious, purulent discharge should have quick referral to an ophthalmologist to preserve vision, if a STD is the probable cause of the infection (Cronau, et al., 2010). It’s also important for sexual partners to get tested (Kumar, 2012). 5. Follow up: This patient should follow up per the recommendations of her ophthalmologist. Identifying the need for a referral to an ophthalmologist is significant in the successful management of conjunctivitis. A referral is wise when a patient presents with severe pain, vision loss or changes, copious, purulent discharge, corneal involvement, an eye injury, distorted pupils, herpes infection, or recurrent infections (Cronau, et al., 2010). CASE STUDY II SOAP NOTE Mary-Kate is a seven-year-old female, Caucasian S: Subjective Chief Complaint (CC): Patient’s mother reports “Mary-Kate has had a red eye for two days now. It started in her left eye spread to her right eye this morning, and she’s been complaining of it itching and burning.” HPI: History of present illness O: Mother reports that her daughter’s has had red left eye for two days and the right one is red since this morning L: Right and left eyes D: Left eye symptoms x two days; right eye started became symptomatic this morning C: Both eyes are red, burning and itching A: No aggravating factors stated. R: No relieving factors stated. T: Tried Visine eye drops, but no relief noted. Patient has taken over the counter cold medicine in the past week or so. PMI: Mother reports Mary Kate had no past illness, injuries, or hospitalizations All immunizations are current No current medications. (OTC cold medicine in the past week, and tried Visine eye drops) Social Mary-Kate lives at home with her parents, Mary and Patrick. Both parents work out of the home full time. Her maternal grandparents also live in the home and help care for the children and household. Mary Kate has younger twin brothers and an older brother. She has two cats and a dog that live in the house. MaryKate is a second grader in parochial school and is considered to be a good student. Family Patient has mother, Mary age 44 and father, Patrick 42 both in good health; four-year-old twin brothers and older brother 10 years old also healthy, Father’s parents died of old age in their 70s.Grandmother has a history of hypertension and hyperlipidemia. Grandfather with hypertension and hyperlipidemia and he uses tobacco since age 10. Father and grandfather both smoke “but not in the house”. There are 2 dogs and a cat that live in the house. Review of Systems (ROS) Constitutional: Denies chills. Weight loss or gain, no appetite changes Eyes: Denies visual loss or changes, denies pain, reports redness, tearing, and itching Ears, Nose, Mouth, Throat: Reports clear nasal drainage and red, swollen nares, denies pain, loss of hearing or changes in hearing, denies pain with swallowing, denies neck or throat pain or swelling. Cardiovascular: Denies chest pain, pressure or palpitations Pulmonary: Denies Shortness of breath or difficulty breathing Lymphatic: Reports slight swelling of anterior neck, denies swelling of axillary lymph nodes O: Objective PE: Physical Exam VS: Height: 46 inches, weight 46 pounds; BP 82/50 T 99.0 P 92 RR 20 BMI 15.3 Constitutional: Female, seven years old, is alert and oriented for age, appropriate when responding and speaking, serenely sitting at mother’s side. Dressed in clean clothes, appropriate for temperature and season. Gait noted and is appropriate. Head: Head normocephalic. Hair is thick with even distribution throughout scalp. Eyes: Vision testing by Snellen chart- right eye: 20/40, left 20/40, together 20/30. No ptosis. No lesions seen. Brows and lashes symmetrical and present without crusting. Tearing noted bilaterally, conjunctiva reddened bilaterally, PERRLA, EOMs intact. Eyelids without erythema or edema. Fundi: red reflex present bilaterally, Discs flat with sharp margins. Vessels present in all Quadrants, no crossing defects. Retinal background has even color, no hemorrhages or bleeding. Macula has an even color. Ears: Tympanic membranes intact with bubbles noted. Pinna and tragus non-tender. No obvious drainage, redness, masses or nodules noted. Nose: Nares with erythema, edematous with clear drainage noted. Throat: Oropharynx moist, uvula is midline. Teeth look healthy, no chips or cracks, no cavities noted. Tonsils ¼ bilaterally. Sinuses nontender to palpation. Neck supple. Anterior cervical lymphadenopathy noted, bilaterally. Thyroid midline, small and firm without palpable masses or nodules. Cardiopulmonary: Heart S1 and s2 sounds, no murmurs. Lungs: Clear to auscultation bilaterally. Respirations effortless. Gastrointestinal: Abdomen soft, symmetrical, non-tender, bowel sounds auscultated in all four quadrants. No organomegaly noted. A: Assessment Diagnosis Adenoviral conjunctivitis (ICD 10 code B30.1) (MediCode, 2016). Adenovirus is the most common cause of viral conjunctivitis. It’s easily transferable, especially in areas with a large population, including public gatherings and community swimming pools. Symptoms include: red eyes, watery eye discharge, and often following a respiratory illness, which the patient is currently recovering from (Quinn, et al., 2011). A rapid adenovirus test for adenoviral conjunctivitis is available, which can help identify an adenovirus infection, thus aiding in the appropriate symptoms management plan (Quinn, et al., 2011). Rationale: Adenoviral conjunctivitis is the primary diagnosis. This is based on the patient’s positive result of rapid adenoviral test, red eyes, watery eye drainage and evidence of a recent cold illness (Quinn, et al., 2011). Diagnosis Otitis media, non-suppurativa (or otitis media with effusion) (ICD 10 code H65) (MediCode, 2016). Otitis media with effusion (OME) is the presence of fluid in the middle ear without signs or symptoms of an acute ear infection. The patient has bubbles in her inner ear, suggesting fluid, but doesn’t complain of pain; with no redness of the TM, suggests the diagnosis of OME (Lieberthal, et al., 2013). P: PLAN 1. Medications: Treatment is supportive and the patient’s symptoms can be comforted by cold compresses, ocular decongestants (like Patanol eye drops) or artificial tears. Topical antibiotic eye drops are seldom necessary because secondary bacterial infections are rare (Cronau, et al., 2010). FDA does not currently have any approved treatments for adenoviral conjunctivitis (Thans & Harwick, 2014). 2. Additional diagnostic tests: None needed at this time. 3. Education: Instruct the child and parent(s) of proper hand washing and the importance of washing often, using warm water and soap (Quinn, et al., 2011). The affected person should use separate bedding, towels, and washcloths than others family members to avoid spreading the infection to others (Quinn, et al., 2011). Adenoviruses are commonly spread by direct contact, water sources, like pool and contaminated objects. It’s very important to wash and sanitize clinical instruments and surfaces after seeing an infected patient (Quinn, et al., 2011). The pathogens are spread through droplets from the respiratory tract and eye, or through such secretions on an intermediate vehicle such as a device, instrument or other object or surface the infected induvial had contact with (Quinn, et al., 2011). Since an ocular infection is contagious for at least seven days, patients should be taught to avoid contact with others for approximately one week from the time symptoms are noticed (Cronau, et al., 2010). Children and adults should be kept from school and other public places, including swimming pools for at least a week after symptoms start. Adenoviruses are vigorous, tough to disinfect and can be transmitted easily in large populations (Cronau, et al., 2010). Adenovirus via the air or personal contact, as in touching an infected person, or items the infected person has touched (CDC, 2015). Handwashing is key to prevention, but because adenoviruses are resistant to many disinfectants, they can remain infectious for a long time on surfaces (CDC, 2015). 4. Referral: None needed An ophthalmologist referral is considered if symptoms do not resolve with 7 to 10 days; if pain intensifies, or drainage becomes mucopurulent (Quinn, et al., 2011). 5. Follow up: Viral conjunctivitis is usually mild and resolves on its own after one to two weeks. The patient should return to the clinic if pain increases, drainage worsens; vision changes, or if current symptoms continue or worsen (Thans & Harwick, 2014). Follow up will be needed only if symptoms continue, or become worse or recurrence of condition occurs (Cronau, et al., 2010). P: PLAN: 1. Medications: Any intervention or treatment for OME (medical or surgical) other than monitoring, may have harmful consequences. Monitoring children with OME, who are not at risk for speech, language, or learning difficulties is associated with little harm (Lieberthal, et al., 2013). No medications at this time. 2. Additional diagnostic tests: The use of a pneumatic otoscope as the primary diagnostic tool should be standard for the clinician. This tool can aid in distinguishing between OME and Acute Otitis Media (AOM) (Lieberthal, et al., 2013). It’s used to test for mobility of the ear drum and has been proven to improve accurate findings of middle ear effusion. Accurate diagnoses of OME is vital to proper medical treatment and symptom management. Additionally, distinguishing OME from AOM will evade unnecessary antibiotic usage. 3. Education: Instruct the patient and parent(s) to monitor patient for ear fullness, difficulty hearing. It a good idea to test hearing when OME lingers for longer than 3 months, or at any time a language delay, learning difficulties, or a noteworthy hearing loss is suspected. 4. Referral: Referral is not needed at this time 5. Follow up: Children with persistent OME, should be reevaluated in 3 to 6 month interludes until the effusion is resolved; or hearing loss, or structural abnormalities of the inner ear are suspected. At each assessment, the clinician should document which ear is afflicted (unilateral or bilateral), extent of effusion, and existence and severity of the symptoms. When the duration of OME is unknown, the clinician should make a reasonable estimate, with the evidence available to him or her (Lieberthal, et al., 2013). Proper documentation aids in appropriate diagnosis, treatment and safeguards patient protection, and helps in reducing errors. References: Centers for D