NR 511 WEEK 2 DISCUSSION 2 (2020)

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NR 511 WEEK 2 DISCUSSION 2 (2020) Patient Information: Mary, 40 yr old F, Caucasian S: CC: Sore Throat HPI: Patient c/o sore throat that began yesterday and is worse when she swallows. She states... she has not eaten or drank anything because it hurts too much. She states it feels like something sharp is in her throat when she swallows. Patient also reports a new onset of fatigue and chills. Patient is currently not taking anything for the pain. She reports the pain 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. 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. 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. Respiratory: Denies cough, difficulty breathing, and shortness of breath or wheezing. Gastrointestinal: No reported bowel problems. No heartburn or indigestion reported. Lymphatics: Denies any enlarged lymph nodes. O:Vital signs: BP 128/72, Temp 101.2, P 100, RR 14 Height: 5' 4" Weight: 149 BMI: 25.6 (overweight) General: Alert, orientated, 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 non-tender. 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. Thyroid midline, small and firm without palpable masses. Cardiovascular: S1 S2 noted, no murmurs, palpitations, chest pain or discomfort noted. Tachycardia. Respiratory: 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, non-tender, bowel sounds present all four quadrants. No organomegaly noted. Lymphatics: Anterior cervical lymph tender to palpation. No lymphadenopathy. Diagnostic results: Rapid strep test positive. A: Streptococcal Pharyngitis (ICD-10 J02.0): Infectious inflammation of the pharynx and the pharyngeal tonsils, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Pharyngitis and tonsillitis us glands. Use caution to not burn the skin unintentionally (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Cool mist humidifier (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Gargle as needed with warm saltwater solution (1 teaspoon of non-iodized salt in 8 ounces of water) (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Bedrest until fever breaks (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Drink plenty of fluids 8-12 glasses daily (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Avoid Smoke (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Take you medication as prescribed until it is finished do not stop taking because you feel good. Change your toothbrush after treatment (Hollier, 2016) Referrals: No referrals as this time. If condition does not resolve with current therapy or becomes worse the patient should be referred to specialist for further assessment and testing, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Foll [Show More]

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