Cleaning soap Notice
FNP 593: Primary Health of Acute Clients/Families Across the Lifespan
United States College
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Cleaning soap Notice #7
Affected person ID: JS
Shopper’s Initials: RH Age: 27 Race: African American Gender: Feminine Date of Beginning:
1/Four/1995
Insurance coverage: BC/BS Marital Standing: Married
Subjective:
CC: “I’ve a cough, runny nostril, and fever and examined constructive for COVID-19 on 1/1/2022, I’m
nonetheless coughing and have congestion”
HPI: JS is an African American feminine, a dependable historian who presents to the clinic
unaccompanied, complaining of a productive cough, sore throat, headache, runny nostril since
12/28/2022 and examined constructive for COVID-19 on 1/1/2022. She has been utilizing Dayquil and
NyQuil to manage signs. She complains of a worsening cough and continued nasal
congestion, she doesn’t have a fever right now however at dwelling temperature had gotten as excessive as 102.7
levels. She complains of evening sweats and likewise has headache ache that she charges 5/10 relieved
by Advil. Denies sick contacts or current journey. Denies seasonal allergic reactions
Previous Medical Historical past:
None
Vaccinations:
All Vaccines Present
TDAP (2020), COVID19 (10/2021) Pfizer x 2 doses, influenza vaccine (2021), Eye examination 2021,
Pap smear 2021.
Surgical procedures: None
Hospitalizations: none
Allergy symptoms: NKA
Drugs:
Dayquil-Four instances a day
Nyquil- pm solely
Advil as wanted for headache
Household Historical past:
Mom 53-no medical historical past
Father: unknown
Social Historical past:
denies smoking, illicit drug use, or alcohol use
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Different:
Lives at dwelling with spouse and daughter
ROS:
Basic: Admits to fever 102.7, weak spot and fatigue. Denies weight change
Eyes: Denies imaginative and prescient change, corrective lenses, ache
redness, extreme tearing, double imaginative and prescient, blurred imaginative and prescient,
or blindness.
Head: Admits to complications 5/10. Denies
lightheadedness, or dizziness.
Eyes: Denies imaginative and prescient adjustments, diplopia, tearing, and scotomata,
Ears: Denies tinnitus, vertigo, discharge, or earache.
Nostril: Admits to nasal congestion, drainage, itching, sneezing. Denies nosebleeds.
Throat: Admits to sore throat. Denies problem swallowing. Final Dental
examination 2020
C/V: Denies chest ache, palpitations.
Pulmonary: Admits to productive Cough. Denies hemoptysis, dyspnea, wheezing, pleuritic ache
Neuro: Admits to headache. Denies dizziness, focal numbness/weak spot, nausea, vomiting.
Lymph: Denies swollen lymph nodes in neck.
Allergy/immunology: Denies seasonal allergic reactions and frequent sickness.
Goal
Important Indicators: HR 898 BP 127/74 Temp 100.2 RR 18 SpO2 97% Ache 5/10
Top 66 in Weight 142 BMI: 24.eight
Labs 7/09/21:
HbA1c 5.5, LDL 50, HDL 49, Choles 97, TG 68, GFR 110,
Bodily Examination
Basic Survey:
Nicely-groomed, well-nourished, cooperative dependable historian, dressed appropriately for the
climate in no acute misery
HEENT
Ears: pinna clear, no exudate famous. TM intact and pearly grey with cone of mild bilat.
Nostril: nasal mucosa pink and moist. Inferior turbinates barely reddened bilat. Nares patent bilat.
No sinus ache upon palpation. Septum midline.
Throat: oral mucosa erythemic, tongue cell with out lesions, tonsils absent. Posterior pharynx
with erythema however no cobblestone look.
Neck: non-tender cervical space, no lymph nodes palpable. Non-enlarged thyroid palpated.
Trachea midline.
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Neuro: Alert and oriented x Four.
Cardio: RRR. Crisp S1 S2 with out clicks or murmurs.
Thorax: Thorax is symmetric with good enlargement. Respirations are even and unlabored. No use
of accent muscle tissue, stridor, grunting, or nasal flaring.
Lungs: Wheezing and congestion Bilaterally
Assessment
DX: COVID-19 Pneumonia (UO7.1)
1. COVID-19 Pneumonia most probably analysis as evidenced by signs and period
2. Viral Pharyngitis-Unlikely as the affected person examined Optimistic for COVID-19
three. Allergic Rhinitis-Unlikely as the affected person doesn’t have seasonal allergic reactions
Plan
DX: COVID-19 Pneumonia (UO7.1)
A: Observe look, damaging for cyanosis, Monitor spO2, 97%, Wheezing and
congested lung sounds
B. Deal with signs with antipyretics and cough drugs, enhance fluids
C: Azithromycin 250mg BID x 5 days, Decadron 6mg x 5 days
E. Affected person to go to Emergency Division for worsening signs or if spO2 drops
beneath 92%.
(Mikkelsen & Abramoff, 2021).
2: Viral Pharyngitis (J02.9)
A: Historical past and Bodily examination,
B: Topical antibiotic or Oral, Augmentin or Cephalexin
C: Oral, Augmentin or Cephalexin
D. Affected person to return if indicators and signs persist or worsen or if new signs develop
(Money, 2021, p. 170-172)
three: Allergic Rhinitis (J30.1)
A: No diagnostic take a look at completed
B: Antihistamine, allergy testing and allergy photographs if indicated
C: Schooling on significance of adhering to medicine regime
D. Return to if signs persist or worsen, or if new signs develop,
(Money 2021, p. 153-156)
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References
Money, J. C., Glass, C. A., & Mullen, J. (2021). Household follow tips (fifth ed.). Springer
Publishing Firm.
Mikkelsen, M.E., & Abramoff, B. (2021). COVID-19: Analysis and administration of adults
following acute viral sickness. UpToDate. Retrieved from
https://www.uptodate.com/contents/covid-19-Assessment-and-management-of-adultsfollowing-acute-viral-illness
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