Exam (elaborations) (SOAP NOTE) NR511 MARY 40 YO FEMALE CAUCASIAN (CC

Exam (elaborations) (SOAP NOTE) NR511 MARY 40 YO FEMALE CAUCASIAN (CC HPI: Patient c/o sore throat that began yesterday and is worse when she swallows. She states she has not eaten or drank anything because it hurts too much. She states it feels like something sharp is in her throat when she swallows. Patient also reports a new onset of fatigue and chills. Patient is currently not taking anything for the pain. She reports the pain 4/5 when swallowing. Current Medications: Daily multivitamin, B complex supplement. Allergies: NKDA. PMHx: Denies any past illness, injuries or surgeries. Hospitalized x2 for childbirth. Soc Hx: Married, drinks alcohol socially, denies tobacco or illicit drug use. Fam Hx: Mary lives with her husband, her parents and her 4 children. Her father and husband both smoke but she states they do not smoke "in the house". Mary also states they have 2 dogs and a cat. ROS: Constitutional: Denies weight loss. Reports new onset of fatigue and chills. HEENT: Denies any headaches and visual changes, wears contact lenses. No reported hearing loss, or ringing in the ears. No reported nasal congestion or discharge. Reports sore throat and difficulty swallowing, denies cough and hoarseness. Cardiovascular: Denies chest pain, palpitations and dizziness. Respiratory: Denies cough, difficulty breathing, and shortness of breath or wheezing. Gastrointestinal: No reported bowel problems. No heartburn or indigestion reported. Lymphatics: Denies any enlarged lymph nodes. O: Vital signs: BP 128/72, Temp 101.2, P 100, RR 14 Height: 5' 4" Weight: 149 BMI: 25.6 (overweight) General: Alert, orientated, and cooperative. This study source was downloaded by from CourseH on :16:52 GMT -05:00 This study resource was shared via CourseH (SOAP NOTE) NR511 MARY 40 YO FEMALE CAUCASIAN (CC Sore Throat) HEENT: Head: Normocephalic. Hair thick and distribution throughout scalp. Eyes: without exudate, sclera clear. Contact lenses noted. Ears: Tympanic membranes gray and intact with cone of light noted. Pinna and tragus non-tender. Nose: Nares patent without exudate. Throat: Oropharynx moist with erythema with white exudate noted. Tonsils 3/4 bilaterally. Teeth in good repair, no cavities noted. Neck supple. Thyroid midline, small and firm without palpable masses. Cardiovascular: S1 S2 noted, no murmurs, palpitations, chest pain or discomfort noted. Tachycardia. Respiratory: Respirations even and unlabored, no distress noted. Lung sounds CTA all anterior and posterior lung fields bilaterally. No SOB, wheezing, or cough observed. Gastrointestinal: Abdomen soft, non-tender, bowel sounds present all four quadrants. No organomegaly noted. Lymphatics: Anterior cervical lymph tender to palpation. No lymphadenopathy. Diagnostic results: Rapid strep test positive. A: Streptococcal Pharyngitis (ICD-10 J02.0): Infectious inflammation of the pharynx and the pharyngeal tonsils, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Pharyngitis and tonsillitis usually occur at the same time and these two diseases are contagious. This is caused by the Group A beta-hemolytic streptococcal infection, which is caused by group A Streptococcus. This can cause scarlet fever or autoimmune rheumatic fever it not treated with antibiotics, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). People diagnosed with this illness must have 2-3 of the following symptoms and if they do the Rapid strep test is performed and antibiotic therapy started symptoms include fever greater than 100.5, tonsillar exudate, tender anterior cervical lymphadenopathy, and no cough (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Mary presents with all these symptoms. P: Medications: Rx: Amoxicillin Amoxicillin 500 mg capsules Sig: 1 cap PO BID Disp #20 (twenty), No refills (Epocrates, 2017). Rx: Acetaminophen Acetaminophen 325 mg 2 tabs PO every 4-6 hours as needed for pain or fever, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Nonprescription throat lozenges as needed for pain, (Dunphy, Winland-Brown, Porter, & This study source was downloaded by from CourseH on :16:52 GMT -05:00 This study resource was shared via CourseH Thomas, 2015). Additional diagnostic tests: None at this time (Hollier, 2016). Education: Apply warm compresses to relieve enlarged, tender cervical lymph glands. Use caution to not burn the skin unintentionally (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Cool mist humidifier (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Gargle as needed with warm saltwater solution (1 teaspoon of non-iodized salt in 8 ounces of water) (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Bedrest until fever breaks (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Drink plenty of fluids 8-12 glasses daily (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Avoid Smoke (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Take you medication as prescribed until it is finished do not stop taking because you feel good. Change your toothbrush after treatment (Hollier, 2016) Referrals: No referrals as this time. If condition does not resolve with current therapy or becomes worse the patient should be referred to specialist for further assessment and testing, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Follow up: Patient to return to clinic for follow-up if symptoms do not start to improve within 3 days of starting the antibiotic, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Patient Information: Tommy 4 yr old M, Caucasian S: CC: Mother states Tommy woke up in the middle of the night saying his ear hurt. He says it hurts to touch. HPI: Patient arrives to clinic with his mother who states her son woke up in the middle of the night saying his ear hurts so bad that it woke him up. He is currently complaining of right ear pain and states it was painful when he was eating breakfast. Patient took Tylenol, but states it did not help. Reports pain as 4/5 on the Wong Baker visual pain scale. This study source was downloaded by from CourseH on :16:52 GMT -05:00 This study resource was shared via CourseH Current Medications: Chewable children’s multivitamin with iron. Allergies: NKDA. PMHx: Full-term pregnancy, NSVD twin gestation 5 pounds 2 ounces. No hospitalizations. Mother denies any past illness or injuries. Denies surgeries. Soc Hx: Single, attends half day K4 program. Always wears seatbelt. Fam Hx: Patient lives at home with parents, grandparents, and 3 siblings. ROS: Constitutional: Denies weight loss, fever, chills, weakness or fatigue. HEENT: Denies any headaches or dizziness. Denies any changes in vision. Denies hearing loss or ringing in the ears, reports ear was itchy yesterday but today it hurts. Denies nasal congestion and discharge. Denies any sore throat or difficulty swallowing. Denies enlarged lymph nodes. Cardiovascular: Denies chest pain, discomfort No reported palpitations. Respiratory: Denies cough, difficulty breathing, and shortness of breath or wheezing. Gastrointestinal: Denies any abdominal pain or changes in bowels. Lymphatics: Denies any enlarged lymph nodes. O: Vital signs: BP 100/60, Temp 98.7, P 94, RR 18, O2 Sat 99%, Height: 3’6” Weight: 39.7 lbs BMI: 15.8 (Underweight) General: Patient is alert, responds appropriately to questions and is cooperative. HEENT: Normocephalic, hair thick and distributed throughout entire scalp. Conjunctiva clear, non-icteric, PERRLA, EOM’s intact. Left ear: tympanic membrane intact with light reflex noted. Pinna/tragus w/o tenderness. No drainage noted in the canal. Right ear: Pain reported on palpation of tragus and with pinna traction. Otoscope exam reveals erythematous, edematous canal with debris noted. The canal edema prevents visualization of the tympanic membrane. Nares patent, unremarkable bilaterally. Pharynx with clear drainage noted, tonsils 2/4 bilaterally. No loose teeth. Neck supple. Cervical lymph w/o lymphadenopathy. Thyroid midline, small, firm. Cardiovascular/Respiratory: Heart RRR w/o murmur. Lungs are clear to auscultation bilaterally. Respirations are unlabored. This study source was downloaded by from CourseH on :16:52 GMT -05:00 This study resource was shared via CourseH Gastrointestinal: Abdomen slightly rounded with active bowel sounds in all 4 quadrants, soft, non-tender, no masses or organomegaly. Lymphatics: No enlarged lymph nodes noted upon palpitation. Lymph node tenderness noted when palpating the pre and post auricular nodes. Testing results: NA A: Right Acute Otitis Externa (ICD 10- H60.91): Otitis Externa is an inflammation of the membranous lining of the auditory canal and/or contiguous structures of the outer ear. Acute otitis externa is a common condition involving inflammation of the ear canal. The acute form is caused primarily by bacterial infection, with Pseudomonas aeruginosa and Staphylococcus aureus the most common pathogens (Schaefer & Baugh, 2012). The most c