Differential dx and etc

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SOAP Note Week Two

United States University

FNP592: Common Illnesses Across the Lifespan

Dr. Theresa Gress

October 1, 2020

SOAP Note Week Three

ID: Mickey Mouse, DOB 1/1/2000, age 20, white Hispanic male presents to the clinic unaccompanied and appears to be a reliable historian.

S:

CC: “Cough, runny nose, and sore throat x 7 days”

HPI: New Asian male patient 28 yo presents to the clinic unaccompanied, complaining of non-productive cough, runny nose and sore throat x 7 days (1/7/2020). Currently somewhat controlling symptoms with Dayquil and Nyquil. Cough mild, worsened when laying flat. Highest temp at home 99 degrees. Patient wondering if he needs antibiotics. Rates pain in throat as 4/10, described as “aching, swallowing makes it worse”, relieved by Dayquil/nyquil. Denies headache, denies sick contacts or recent travel. Denies feeling worse outdoors or seasonally. He is a reliable historian

PMH:

Allergies: No known drug allergies. Strawberries (rash), seasonal allergies
Childhood: Asthma until high school, chickenpox at age 2

Surgical: Tonsillectomy (1998), Wisdom Teeth Removal (2005)

Medications: None

Vaccinations: received childhood vaccines, Last flu shot given Oct 2019.

Denies psychiatric history.

Social History:

Denies tobacco/e-cigarette use. Admits to occasional once every 2-3 months alcohol use – last drink

2 months ago, Engaged, works in IT, Hobbies include archery.

Family History:

Mother died age 60-Diabetes II
Sister 42yo living -HTN
Maternal Grandma died age 67- Dementia

ROS:

General: No weight change, weakness, fatigue, fevers..

Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred vision, or blindness.
EarsNose/Throat/mouth: no hearing change, tinnitus, earaches, infection, discharge. POSITIVE FOR RHINORRHEA. No sinus pain or epistaxis. POSITIVE FOR SORE THROAT, HOARSE VOICE. No bleeding gums, dentures, sore tongue, dry mouth. Last dental exam was 4 months ago.

C/V: Denies chest pain, palpitations.
Pulmonary: POSITIVE FOR NON-PRODUCTIVE COUGH, negative hemoptysis, dyspnea, wheezing, pleuritic pain
Neuro: No headache, dizziness, focal numbness/weakness, nausea, vomiting.

Lymph: Denies swollen lymph nodes in neck.

Allergy/immunology: Denies seasonal allergies or allergy to pets, pollen or other. Denies frequent illness.

O:

VS: T – 98 P – 80 R – 16 BP – 128/72 O2 sat – 99% – 4/10 pain in throat. Wt: 205 Ht: 72 in BMI: 27.8

Skin: Natural in color, warm, smooth and dry. Good skin turgor, no lesions, rashes, ecchymosis or moles. Nails without clubbing or cyanosis.

HEENT:

Ears: pinna clean, no exudate noted. TM intact and pearly gray with cone of light bilat.
Nose: nasal mucosa pink and moist. Inferior turbinates slightly reddened bilat. Nares patent bilat. No sinus pain upon palpation. Septum midline.
Throat: oral mucosa pink and moist, tongue mobile without lesions, tonsils absent. Posterior pharynx with erythema but no cobblestone appearance.
Neck: non-tender cervical area, no lymph nodes palpable. Non-enlarged thyroid palpated. Trachea midline.
Neuro: Alert and oriented x 4.
Cardio: RRR. Crisp S1 S2 without clicks or murmurs.

Thorax and lungs: Thorax is symmetric with good expansion. Respirations are even and unlabored. No use of accessory muscles, stridor, grunting, or nasal flaring. Lungs CTA Bilaterally.

(***notice not all systems are in the PE when doing a focused exam on a problem)

A:

Differential DDX: INCLUDE AT LEAST 3 DIFFERENTIALS

1. Viral pharyngitis – most likely as evidenced by sore throat, cough, no fever (Stead, 2019). (←←←←←that is a practice treatment guideline)

2. Strep Throat – not as likely; no fever and 7 days duration, age not as consistent with this dx

3. Allergic rhinitis – no report of sx increasing with outdoor activity or exposure to allergens, sx with sore throat are less likely for allergies.

DX: Viral pharyngitis

P:

In house throat swab for rapid strep – negative.

Continue to rest and drink lots of fluids (Cash & Glass, 2017; Stead, 2019).

Continue OTC Dayquil/Nyquil PRN per directions on the box – Safe dosing discussed, sedation may occur with Nyquil, avoid driving or operating heavy machinery after taking.

Encourage tea with honey and lemon to help with cough and sore throat.

Gargle with warm salt water 2-3 times a day for 30 sec, swish and spit.

Do not drink alcohol while taking these medications.

Cover mouth when coughing, do not drink after other people (Cash & Glass, 2017).

Return to office in 3-4 days if symptoms do not improve, worsen, or get better and then again get worse (Cash & Glass, 2017).
Call 911 or go to ER for trouble breathing or any other emergent concern (Stead, 2019).

References:

Cash, J. & Glass, C. (2017).
Family practice guidelines. New York, NY. Springer.

Stead, W. (2019). Symptomatic treatment 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

SOAP Note Week Three: Acute Pharyngitis

Student

United States University

FNP592: Common Illnesses Across the Lifespan

Professor

November 14, 2022

SOAP Note Week three: Acute Pharyngitis

ID:

Client’s Initials: J.K Age: 68 Race: Hispanic Gender: Male Date of Birth: November 1, 1954

Marital Status: Married

The patient presented to the clinic accompanied by daughter.


Subjective:

CC: “sore throat that started 3 days ago”

HPI:

The 68-year-old Hispanic male presents to the clinic with complaints of sore throat associated with neck pain and trouble swallowing. The onset of the symptoms was 3 days ago. Patient denies cough, fever or chills, runny nose, nasal congestion, nausea and shortness of breath. He denies sick contacts. He took COVID test this morning and it is negative. He has not taken any medication for the symptoms.

Past Medical History:

· Medical problem list: Hypertension, Diabetes, Hypothyroidism and Hyperlipidemia

· Preventative care: Annual influenza vaccine, complete COVID vaccine, eye, and hearing screening every year

· Surgeries: None

· Hospitalizations: no history of hospitalization.

Allergies: Has no known allergies

Medications: Metformin 500mg 2 times a day for diabetes, Lisinopril 40 mg once a day, Atorvastatin 20mg once daily, Levothyroxine 50mcg once daily

Family History: history of diabetes (father-deceased), hypertension (mother-deceased)

Social History: The patient is married, and he lives with his wife and children. He does not smoke cigarettes or take alcohol. He is a Catholic and attends church every Sunday. He has dogs that he walks in the park every morning.

Review of System

Constitutional: Denies fever, chills, fatigue or weight changes

Head/Eyes/Ears/Nose/Mouth: Denies headaches, eye pain or discharge, no ear pain, nasal congestion, rhinorrhea or mouth sores

Throat: Complaints of sore throat, neck pain and pain when swallowing.

Cardiovascular: Denies report chest pain, SOB, palpitations, or chest pressure

Pulmonary: Denies shortness of breath, cough, wheezing, or chest wall pain with breathing

Gastrointestinal: Denies poor appetite, nausea, vomiting, abdominal pain, constipation, or diarrhea.

Neurological: denies dizziness, headache, seizures, problems, weakness

Psychiatric: Denies depression, anxiety, mood swings, memory loss, or insomnia

Hematologic/Lymphatic denies any swellings

Allergic/Immunologic: Denies allergies, denies frequent infections


Objective

Vital Signs: HR-76 BP-120/80 Temp-98F RR-18 SpO2-99% Pain-5/10 pain in the throat

Height- 167.6cm Weight -91kgs BMI – 32.44kg/m2

Physical Exam

General: Well-developed, obese, age appropriate. Well groomed, interactive in no acute distress. Vitals reviewed and stable.

Ears: Right and left ear: tympanic membrane is gray, non-bulging and freely mobile. No discharge, no foreign body noted on external canal.

Nose: Nares patent bilaterally. No epistaxis, rhinorrhea, purulent discharge, sinus tenderness or deviated nasal septum noted.

Oral cavity and pharynx: lips, teeth, and gums are in good general condition. Posterior oropharynx has erythema but no exudate, lesions, or cobblestoning.

Neck: No lymphadenopathy, neck tenderness, diffuse enlargement of the thyroid noted

Pulmonary: Clear to auscultation to all lung fields. No shortness or breath, labored breathing, or use of accessory muscles noted.

Cardiovascular: Normal S1 and S2. No murmurs. Rhythm is regular. There is no peripheral edema, cyanosis, or pallor. Extremities are warm and well perfused, without clubbing, cyanosis or edema. Capillary refill is less than 2 seconds.

Extremities: No palpable cords and there is no pain with palpation. Digits and nails are normal.


Assessment

Differentials

1.

2.

3.

Diagnosis

1.
Acute pharyngitis


Plan

Diagnostics:

Treatment:

Education

Follow Up:

References

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