Week 4: 70 Year-Old African America Female With Uncontrolled Diabetes
Week 4: 70 Year-Old African America Female With Uncontrolled Diabetes
EXAMPLE 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. Week 4: 70 Year-Old African America Female With Uncontrolled Diabetes. 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). PMH: 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: Diabetes II (Mother) HTN (Older sister – 42 years old) Dementia (Maternal Grandmother) 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 RHINORHEA. No sinus pain or epistaxis. POSITIVE FOR SORE THROAT, HOARSE VOICE. No bleeding gums, dentures, sore tongue, dry mouth. Last dental exam 4 months ago. Week 4: 70 Year-Old African America Female With Uncontrolled Diabetes. C/V: Denies chest pain, palpitations.
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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. Allery/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. A: Differential DDX: INCLUDE AT LEAST 3 DIFFERENTIALS Viral pharyngitis – as evidenced by sore throat, cough, no fever Strep Throat – not as likely; no fever and 7 days duration, age not as consistent with this dx 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). 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. 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. Week 4: 70 Year-Old African America Female With Uncontrolled Diabetes
