SOAP Notice Week Two
United States College
FNP592: Common Illnesses Across the Lifespan
Dr. Theresa Gress
October 1, 2020
SOAP Notice Week Three
ID: Mickey Mouse, DOB 1/1/2000, age 20, white Hispanic male presents to the clinic unaccompanied and seems to be a dependable historian.
S:
CC: “Cough, runny nostril, and sore throat x 7 days”
HPI: New Asian male affected person 28 yo presents to the clinic unaccompanied, complaining of non-productive cough, runny nostril and sore throat x 7 days (1/7/2020). Presently considerably controlling signs with Dayquil and Nyquil. Cough gentle, worsened when laying flat. Highest temp at dwelling 99 levels. Affected person questioning if he wants antibiotics. Charges ache in throat as Four/10, described as “aching, swallowing makes it worse”, relieved by Dayquil/nyquil. Denies headache, denies sick contacts or current journey. Denies feeling worse outside or seasonally. He’s a dependable historian
PMH:
Allergy symptoms: No identified drug allergy symptoms. Strawberries (rash), seasonal allergy symptoms Childhood: Bronchial asthma till highschool, chickenpox at age 2
Surgical: Tonsillectomy (1998), Knowledge Enamel Removing (2005)
Drugs: None
Vaccinations: obtained childhood vaccines, Final flu shot given Oct 2019.
Denies psychiatric historical past.
Social Historical past:
Denies tobacco/e-cigarette use. Admits to occasional as soon as each 2-Three months alcohol use – final drink
2 months in the past, Engaged, works in IT, Hobbies embrace archery.
Household Historical past:
Mom died age 60-Diabetes II Sister 42yo residing -HTN Maternal Grandma died age 67- Dementia
ROS:
Common: No weight change, weak spot, fatigue, fevers..
Eyes: no imaginative and prescient change, corrective lenses, ache redness, extreme tearing, double imaginative and prescient, blurred imaginative and prescient, or blindness. EarsNose/Throat/mouth: no listening to change, tinnitus, earaches, an infection, discharge. POSITIVE FOR RHINORRHEA. No sinus ache or epistaxis. POSITIVE FOR SORE THROAT, HOARSE VOICE. No bleeding gums, dentures, sore tongue, dry mouth. Final dental examination was Four months in the past.
C/V: Denies chest ache, palpitations. Pulmonary: POSITIVE FOR NON-PRODUCTIVE COUGH, damaging hemoptysis, dyspnea, wheezing, pleuritic ache Neuro: No headache, dizziness, focal numbness/weak spot, nausea, vomiting.
Lymph: Denies swollen lymph nodes in neck.
Allergy/immunology: Denies seasonal allergy symptoms or allergy to pets, pollen or different. Denies frequent sickness.
O:
VS: T – 98 P – 80 R – 16 BP – 128/72 O2 sat – 99% – Four/10 ache in throat. Wt: 205 Ht: 72 in BMI: 27.eight
Pores and skin: Pure in colour, heat, easy and dry. Good pores and skin turgor, no lesions, rashes, ecchymosis or moles. Nails with out clubbing or cyanosis.
HEENT: Ears: pinna clear, no exudate famous. TM intact and pearly grey with cone of sunshine 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 pink and moist, tongue cellular 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. Neuro: Alert and oriented x Four. Cardio: RRR. Crisp S1 S2 with out clicks or murmurs.
Thorax and lungs: Thorax is symmetric with good enlargement. Respirations are even and unlabored. No use of accent muscle groups, stridor, grunting, or nasal flaring. Lungs CTA Bilaterally.
(***discover not all methods are in the PE when doing a targeted examination on an issue)
A:
Differential DDX: INCLUDE AT LEAST Three DIFFERENTIALS
1. Viral pharyngitis – most definitely as evidenced by sore throat, cough, no fever (Stead, 2019). (←←←←←that could be a follow therapy guideline)
2. Strep Throat – not as possible; no fever and seven days length, age not as in line with this dx
Three. Allergic rhinitis – no report of sx rising with out of doors exercise or publicity to allergens, sx with sore throat are much less possible for allergy symptoms.
DX: Viral pharyngitis
P:
In home throat swab for fast strep – damaging.
Proceed to relaxation and drink a number of fluids (Money & Glass, 2017; Stead, 2019).
Proceed OTC Dayquil/Nyquil PRN per instructions on the field – Secure dosing mentioned, sedation could happen with Nyquil, keep away from driving or working heavy equipment after taking.
Encourage tea with honey and lemon to Help with cough and sore throat.
Gargle with heat salt water 2-Three occasions a day for 30 sec, swish and spit.
Don’t drink alcohol whereas taking these drugs.
Cowl mouth when coughing, don’t drink after different folks (Money & Glass, 2017).
Return to workplace in Three-Four days if signs don’t enhance, worsen, or get higher after which once more worsen (Money & Glass, 2017). Name 911 or go to ER for bother respiration or another emergent concern (Stead, 2019).
References:
Money, J. & Glass, C. (2017). Household follow tips. New York, NY. Springer.
Stead, W. (2019). Symptomatic therapy of acute pharyngitis in adults. In L. Kunnis
(Ed.). UpToDate Retrieved February 12, 2020 from:
https://www.uptodate.com/contents/symptomatic-treatment-of-acute-pharyngitis-
in-adults
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Week Two of SOAP Notes
College of the United States of America
FNP592: Common Illnesses All through One’s Life
Theresa Gress, Ph.D.
1st of October, 2020
Week Three SOAP Notes
Mickey Mouse, DOB 1/1/2000, age 20, white Hispanic male, arrives unaccompanied at the clinic and seems to be a reliable historian.
S:
CC: “7 days of cough, runny nostril, and painful throat”
HPI: A 28-year-old Asian male affected person arrives alone at the clinic, complaining of a non-productive cough, runny nostril, and sore throat for the previous seven days (1/7/2020). Dayquil and Nyquil are presently serving to to scale back signs. Gentle cough that will get worse when mendacity flat. At dwelling, the highest temperature reached 99 levels. Affected person is not sure if he requires antibiotics. Dayquil/nyquil relieves ache in the throat, which she describes as “aching, swallowing makes it worse.” Denies having a headache.
