NUR6512 WEEK 5 ASSESSMENT SOAP NOTE

NUR6512 WEEK 5 ASSESSMENT SOAP NOTE

NUR6512 WEEK 5 ASSESSMENT SOAP NOTE

SOAP NOTES – WEEK 5 ASSESSMENT

Walden University

NUR6512 – Advanced Health Assessment and Diagnostic Reasoning

Patient Initials: LW Age: 20 Gender: Female

Case Study 2

SUBJECTIVE DATA:

Chief Complaint (CC): Patient states that she has heard of flu-like symptoms being present across the college campus. Patient complains of having no appetite and having so sore throat.

This has been happening for the past three days.

History of present illness: Lily Weaver is 20 years old. She is well nourished, appropriately groomed white Caucasian female with well-maintained  hygiene came to the clinic today strong headache, painful swallowing, nasal discharge, significantly reduced appetite. Patient denies any symptoms of nausea, vomiting, fever and any other distress. NUR6512 WEEK 5 ASSESSMENT SOAP NOTE

She has expressed that she is concerned based on things that she has heard regarding cases of the flu being diagnosed across the campus. It is noted that patient’s voice sounds strained and hoarse while answering questions. Patient states that she has been taking Tylenol for symptoms and using Cepacol lozenges for throat pain.

Medications:

Tylenol 200mg q.6.h.

Ortho Tri-Cyclin 0.180mg q.h.s.

Cepacol for the sore throat 4 times a day

Allergies: NKA

Past Medical History (PMH):

Measles -at the age of 7

Chicken pox – at the age of 5

Past Surgical History (PSH):

Appendectomy – Age 12 (2008)

Sexual/Reproductive History:

Patient denies any prior diagnosis of STD’s. She is in an active heterosexual relationship with regular intercourse. Patient protects against pregnancy using birth control and requires her long-term boyfriend to use condom. Last menstrual cycle based on patients’ calendar was 9/15/2020.

Personal/Social History:

Patient is active, social college student. She actively participates in several clubs, and volunteers on campus. She states that she drinks occasionally, maybe 1-2 times a month at parties. Patient denies any usage of the illicit drugs in the past and in present time. NUR6512 WEEK 5 ASSESSMENT SOAP NOTE

Immunization History:

Immunizations up to date as per record.

Vaccinations for TD is last received in January 2019.

Annual vaccination for influenza received at September 2020.

 

Family Medical History:

Hypertension – maternal grandparents, mother

Diabetes – father, and paternal mother

Denies any other significant family history related to health concerns.

Review of Systems:

General: Lily is pleasant, well groomed, able to communicate clearly, and has provided through personal and family medical history. She is cooperative with examination process.

NUR6512 WEEK 5 ASSESSMENT SOAP NOTE HEENT: As per assessment, there are no signs of headache, eye pain, blurry vision, visual changes or the discharge, no sinus pressure, sneezing or runny nose. No mouth or tooth pain, no difficulty swallowing. No ear pain or discharge. No dandruff or scalp lesions. No redness or other inflammatory or traumatic signs. Recent onset of rhinorrhea (3 days ago). Redness noted on the back of the throat. Tonsils are have the signs of inflammation appears to infected and swollen. Patient denies coughing. Hoarseness noted during conversations as well as persistent clearing of throat. NUR6512 WEEK 5 ASSESSMENT SOAP NOTE

Breasts: Equal bilaterally, no signs and symptoms of the discharge, nodules or asymmetry are noted.

Respiratory:  Patient not in acute obvious  distress, no unlabored breating pattern noted,  symmetrical chest, equally and  evenly raising during respirations. Fremitus normal. Breath sounds clear and unlabored bilaterally in all fields. Tympanic resonance to percussion anterior and posterior chest assessed  no dullness noted.

Cardiovascular/Peripheral Vascular: Negative for chest pain, edema, palpitations, murmurs, or syncope.

Gastrointestinal: Patient denies nausea and vomiting. Does report decreased appetite with onset of sore throat. Bowel patterns are daily and regular. Denies any symptoms of constipation or diarrhea.

Lymphatics: Palpation of the cervical lymph nodes revealed mild inflammatory symptoms as swelling and tenderness. NUR6512 WEEK 5 ASSESSMENT SOAP NOTE

OBJECTIVE DATA:

Physical Exam:

Vital signs: 11 BP 124/78 (right arm, small cuff, sitting) | Pulse 68 | Temp 99.6F (Oral) | Resp 18 (non-labored) | Ht 5’3”. | Wt 126 lb) | BMI 19 kg/m2.

General: Patient is Alert , oriented to person  time place and situation. She is the good reliable historian. Patient offers all information freely and without contradiction. Speech coherent free clear and understandable. Speaking using full sentences. She appears well mannered, well-nourished and maintains eye contact throughout the interview. No distress noted.

ASSESSMENT:

Laboratory tests performed:

Comprehensive metabolic panel, complete blood count, rapid streptococcus test, influenza test.

Results:

CMP-Normal

BMP-Normal

Rapid streptococcus test-positive

Influenza test-

Differential Diagnosis:

1) Streptococcal Pharyngitis – Symptoms presented by patient are often associated with Streptococcal Pharyngitis. 7 Typically causes fever, generalized malaise, painful swallowing, and cervical lymphadenopathy. 8 Diagnosis of Streptococcal Pharyngitis based on physical exam, and patient history are insufficient alone. Diagnosis can be confirmed by rapid strep test or throat culture (Gottlieb, Long, Koyfman, 2018).

2) Influenza – This diagnosis should be considered based on patient data, and current outbreaks diagnosed on college campus. 3 Symptoms of influenza include cough, fever, headache, malaise, and sore throat (Ball, et al, 2015). Patient has multiple symptoms matching this diagnosis. While patient has been vaccinated for flu, it should be noted that this is not always effective, and flu diagnosis is still possible. Diagnosis can be confirmed with the use of “Rapid Influenza Diagnostic Test”. Results can be determined in 15-20 minutes (Antonio, et al, 2018 NUR6512 WEEK 5 ASSESSMENT SOAP NOTE).

13 3) Acute Laryngitis – common symptoms are noted as hoarseness, sore throat, cough, and voice fatigue resulting from inflammation of the interarytenoid area in the larynx (Pendleton, Ahlner-Elmqvist, Jannert, & Ohlsson, 2013).

4) Sinusitis – Sinusitis is a bacterial infection caused by inflammation in nasal passages, allergies, or structural defects. This may cause drainage from the sinus cavities. Symptoms often include headache, facial pressure, nasal discharge, or nasal congestion, and fevers (Ball et al, 2015 NUR6512 WEEK 5 ASSESSMENT SOAP NOTE).

9 5) Diphtheria – Symptoms are noted as sore throat, fever, tender cervical lymph nodes. 5 This condition destroys healthy tissues contained with the respiratory system and can cause thickening, gray coating within the nose and throat referred to as pseudomembrane (Centers for Disease Control and Prevention, 2016).

NUR6512 WEEK 5 ASSESSMENT SOAP NOTE References

Antoniol, S., Fidouh, N., Ghazali, A., Ichou, H., Bouzid, D., Kenway, P.,. Casalino, E. (2018). Diagnostic performances of the Xpert® Flu PCR test and the OSOM® immunochromatographic rapid test for influenza A and B virus among adult patients in the Emergency Department. Journal of Clinical Virology, 99–100, 5–9. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jcv.2017.12.005

Ball, J. 1 W., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2015). Seidel’s guide to physical examination (8th Edition). St. Louis, MO: Elsevier Mosby.

Centers for Disease Control and Prevention [CDC], (2016). Diphtheria. Retrieved from: https://www.cdc.gov/diphtheria/about/symptoms.html

Gottlieb, M., Long, B., & Koyfman, A. (2018). Clinical Mimics: 8 An Emergency Medicine-Focused Review of Streptococcal Pharyngitis Mimics. JOURNAL OF EMERGENCY MEDICINE, 54(5), 619–629. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jemermed.2018.01.031

Pendleton, H., Ahlner-Elmqvist, M., Jannert, M., & Ohlsson, B. (2013). Posterior laryngitis: a study of persisting symptoms and health-related quality of life. European Archives of Oto-Rhino-Laryngology: Official Journal of The European Federation of Oto-Rhino-Laryngological Societies (EUFOS): Affiliated with The German Society for Oto-Rhino-Laryngology – Head and Neck Surgery, 270(1), 187–195. https://doi-org.ezp.waldenulibrary.org/10.1007/s00405-012-2116-2

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