SOAP NOTES NURS 511 WEEK 2

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Patient Information: M., 40 years old, F, Caucasian Subjective Data CC: sore throat HPI: Patient states she has a sore throat this morning, throat has hurt since yesterday, and hurts worse when s... he swallows. She has not eaten or drank anything because it hurts too much. Reports feels like something sharp is in her throat when she swallows. Not currently taking anything for the pain. Reports pain of 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. Obstetrical Hx: Gravida 2, Para 3. 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, fever, and weakness. But 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. No reported cardiac history. Respiratory: Denies cough, difficulty breathing, and shortness of breath or wheezing. Gastrointestinal: No reported bowel problems. Lymphatics: Denies any enlarged lymph nodes. Objective Data This study source was downloaded by 100000850647391 from CourseHero.com on 10-03-2022 10:24:10 GMT -05:00 https://www.coursehero.com/file/18197860/SOAP-Note-week-two-NR511/ SOAP NOTES NURS 511 WEEK 2 Vital signs: BP 128/72, Temp 101.2, P 100, RR 14 Height: 64 inches (5' 4") Weight: 149 BMI: 25.6 Constitutional: Patient is alert, oriented and cooperative. 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 nontender. 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. Anterior cervical lymph tender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. Cardiovascular/Respiratory: S1 S2 noted, RRR, no murmurs, palpitations, chest pain or discomfort noted. 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, nontender, bowel sounds present all 4 quadrants. No organomegaly noted. Lymphatics: No enlarged lymph nodes noted upon palpitation. Assessment: Testing results: Rapid strep test positive- this indicates a streptococcal infection. If the test was negative then a throat swab would be obtained. Streptococcal Pharyngitis ICD-10 J02.0- this is an 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, (Kalra, Higgins, & Perez, 2016). 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. Mary presents with all these symptoms. Plan: Medications: Amoxicillin 500 mg po TID times 10 days, (Wirfs 2017). This study source was downloaded by 100000850647 [Show More]

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