Episodic/Focused SOAP Note, Assignments of Nursing

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Running head: EPISODIC/FOCUSED SOAP NOTE 1 Episodic/Focused SOAP Note Ming Zhang Walden University NURS 6531 Due Date

Episodic/Focused SOAP Note Patient Information: Initials: E.D. Age:22 Sex: female Race: white S. CC: Ms. ED is here for sore throat over one week and half ago. HPI : Ms. ED is 22-year-old Caucasian female. She is here because of sore throat for over one week and half. She also has compliant of other symptoms, include bad cough, nasal congestion and lost voice due to swollen throat. She states her cough is productive with yellow sputum and worsened with swallowing and speaking. She smoked cigarettes yesterday. She denies of fever or take any OTC medication. Denies SOB, chest discomfort, wheezing or history of asthma. Current Medications : Cyanocobalamin 100mcg/ml Injection subcutaneously every 30 days for anemia Ergocalciferol 50,000unit by mouth weekly x6 weeks, then 50,000 PO monthly for vitamin D deficiency Loratadine 10mg by mouth daily as needed for allergic rhinitis/cough Phentermine HCL 37.5mg by mouth daily for weight loss Triamcinolone Acetonide 0.025% 1 application topically to affected area 2 times per day for arm rash Allergies: No Known Drug Allergy PMHx : Urinary tract infection, Obesity, Chlamydial infection, Anxiety disorder. PSHx : Denies of past surgical history. Pt reported had polio and tetanus vaccine. Soc Hx : Patient denies of drink alcohol. She smokes 1-9 cigarettes per day. She is on medications to control her weight. She exercises regularly.

Heart/Peripheral Vascular: RR without murmur. No rub or gallop; pulses palpable + bilateral pedal and +2 bilateral radial ABD: soft, non-tender, non-distended, no mass. BS normal. Skin: Warm, no rash. No lesions noted. Diagnostic results : Rapid strep antigen test The rapid streptococcus antigen test is an accurate and quick tool for streptococcus detection. It has a sensitivity approximately of 70% to 90% to evaluate whether streptococci are present in the patient’s throat. In order to rule out streptococcal infection, rapid strep antigen test is necessary for Ms. ED due to her symptoms (sore throat and painful throat). Rapid influenza test The rapid influenza testing has a sensitivity ranging from 50%-70%, which indicate that over half of the influenza cases, the flu swab results will still be negative (Canha & Osakwe, 2019). For this patient, I will still consider this test due to her clinical magnifications of cough, congestion and sore throat. A. Differential Diagnoses Acute Bronchitis It is a sudden inflammation in bronchial tube causing edema of the bronchus. Patient most common suffer from virus infection than bacterial infection. In fact, there are only less than 10% of acute bronchitis cases are constitute by bacterial infection (Dempsey, Businger, Whaley, Gagne & Linder, 2014). Ms. ED has no fever, in this case, I would more consider the possibility of a bacterial infection. Acute bronchitis is characterized by a prolonged and productive cough that bring up green or yellow phlegm, sore throat. Those symptoms are associate with patient’s clinical manifestations. Streptococcal pharyngitis Streptococcal pharyngitis is very common and usually lasts about one week with the complaints of sore throat, painful swallowing and swollen lymph nodes. The throat and tonsils are commonly affected. S.pyogenes is the common organism involved in the group A strep pharyngitis. Patient with the disease often present with sudden onset of sore throat, tonsillar

erythema, green-yellowish mucus (National Institute for Health and Care Excellence, 2016). The center criteria to rule out this disease include fever, absence of cough, tender of the lymph nodes and palatal petechiae (Skapetis &Fong, 2016). Pending rapid strep antigen test. Influenza Influenza is usually preceded by viral infection of respiratory system causing inflammatory changes in nose, throat, and sometimes the lung, which results in mild to severe illness. Influenza is contagious and usually presents with cough, headaches, sore throat, fever or muscle or body aches. This illness is associated with the clinical magnification of pharyngitis and rhinitis (Smith, Fahey, Smucny & Becker, 2017). Influenza commonly present with headache, fever, body aches and chest discomfort while cough. Therefore, pending influenza test to rule out the diagnosis. P. EKG ordered for tachycardia and mild hypotension. EKG showed normal sinus with HR of

Recommend antibiotics therapy for cough up thick, yellow or green mucus last for more than a week (Sweet, V., 2018).  Amoxicillin 500mg by mouth every 12 hrs for 10 days.  Ibuprofen 600mg by mouth 2 times per day for throat pain.  Medrol 4mg oral tablet therapy pack for inflammation Advise humidified air at home to increase humidity, it is important to relieve dryness in the nose and throat and liquefy secretions. Recommended to increased fluid intake but avoid alcohol and caffeine Avoid exposure to cigarette smoke, dust and strong fumes. Recommended to use nasal spray to relieve nose congestion. Recommended to quit smoking to reduce the risk of developing smoking-rated disease Advise patient to follow up in 2 weeks if symptoms persist despite the treatment

References Dempsey, P. P., Businger, A. C., Whaley, L. E., Gagne, J. J., & Linder, J. A. (2014). Primary care clinicians’ perceptions about antibiotic prescribing for acute bronchitis: a qualitative study. BMC family practice , 15 (1), 194. Goyal, H., Awad, H. H., & Ghali, J. K. (2019). Role of cannabis in cardiovascular disorders. JOURNAL OF THORACIC DISEASE , 9 (7), 2079–2092. https://doi- org.ezp.waldenulibrary.org/10.21037/jtd.2017.06. National Institute for Health and Care Excellence (2016) Sore throat (acute): antimicrobial prescribing. Retrived from https://www.clinicalkey.com/nursing/#!/content/nice_guidelines/65- s2.0-NG Skapetis, T & Fong, J (2016) Dental, ear, nose and throat emergencies. Emergency and Trauma Care for Nurses and Paramedics. https://www.clinicalkey.com/nursing/#!/content/book/3-s2.0-B978072954298200031X? scrollTo=%23top Sweet, V., & Emergency Nurses Association. (2018). Emergency nursing core curriculum. Retrived from https://www.clinicalkey.com/nursing/#!/content/book/3-s2.0- B Smith, S. M., Fahey, T., Smucny, J., & Becker, L. A. (2017). Antibiotics for acute bronchitis. The Cochrane database of systematic reviews, 6(6), CD000245. doi:10.1002/14651858.CD000245.pub