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NR511 week 2 discussions STUDY GUIDE
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 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. 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 (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Mary presents with all these symptoms. P: Medications: Rx: Amoxicillin Amoxicillin 500 mg capsules Sig: 1 cap PO BID Disp #20 (twenty), No refills (Epocrates, 2017). Rx: Acetaminophen Acetaminophen 325 mg 2 tabs PO every 4-6 hours as needed for pain or fever, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Nonprescription throat lozenges as needed for pain, (Dunphy, Winland-Brown, Porter, &
Current Medications: Chewable children’s multivitamin with iron. Allergies: NKDA. PMHx : Full-term pregnancy, NSVD twin gestation 5 pounds 2 ounces. No hospitalizations. Mother denies any past illness or injuries. Denies surgeries. Soc Hx: Single, attends half day K4 program. Always wears seatbelt. Fam Hx: Patient lives at home with parents, grandparents, and 3 siblings. ROS: Constitutional: Denies weight loss, fever, chills, weakness or fatigue. HEENT: Denies any headaches or dizziness. Denies any changes in vision. Denies hearing loss or ringing in the ears, reports ear was itchy yesterday but today it hurts. Denies nasal congestion and discharge. Denies any sore throat or difficulty swallowing. Denies enlarged lymph nodes. Cardiovascular: Denies chest pain, discomfort No reported palpitations. Respiratory: Denies cough, difficulty breathing, and shortness of breath or wheezing. Gastrointestinal: Denies any abdominal pain or changes in bowels. Lymphatics: Denies any enlarged lymph nodes. O: Vital signs: BP 100/60, Temp 98.7, P 94, RR 18, O2 Sat 99%, Height: 3’6” Weight: 39.7 lbs BMI: 15.8 (Underweight) General: Patient is alert, responds appropriately to questions and is cooperative. HEENT: Normocephalic, hair thick and distributed throughout entire scalp. Conjunctiva clear, non-icteric, PERRLA, EOM’s intact. Left ear: tympanic membrane intact with light reflex noted. Pinna/tragus w/o tenderness. No drainage noted in the canal. Right ear: Pain reported on palpation of tragus and with pinna traction. Otoscope exam reveals erythematous, edematous canal with debris noted. The canal edema prevents visualization of the tympanic membrane. Nares patent, unremarkable bilaterally. Pharynx with clear drainage noted, tonsils 2/4 bilaterally. No loose teeth. Neck supple. Cervical lymph w/o lymphadenopathy. Thyroid midline, small, firm. Cardiovascular/Respiratory: Heart RRR w/o murmur. Lungs are clear to auscultation bilaterally. Respirations are unlabored.
Gastrointestinal: Abdomen slightly rounded with active bowel sounds in all 4 quadrants, soft, non-tender, no masses or organomegaly. Lymphatics: No enlarged lymph nodes noted upon palpitation. Lymph node tenderness noted when palpating the pre and post auricular nodes. Testing results: NA A : Right Acute Otitis Externa (ICD 10- H60.91): Otitis Externa is an inflammation of the membranous lining of the auditory canal and/or contiguous structures of the outer ear. Acute otitis externa is a common condition involving inflammation of the ear canal. The acute form is caused primarily by bacterial infection, with Pseudomonas aeruginosa and Staphylococcus aureus the most common pathogens (Schaefer & Baugh, 2012). The most common presenting complaint of patients with otitis externa is an acute, often severe otalgia of sudden or gradual onset, which may present bilaterally. Pain may be worse at night and disturb sleep, and it is exacerbated by pulling the pinna or earlobe or by applying pressure to the tragus. In early stages, the ear may feel full or obstructed, and a temporary conductive hearing loss is common if edema is severe (Dunphy, Winland-Brown, Porter, & Perez, 2015). Tommy is presenting with sudden ear pain during the night that woke him up from his sleep. Pain reported a 4/5 Wong Baker scale. Ear felt itchy and now hurts. Ear pain also while eating as per patient. Right ear reports pain on palpation of tragus and pinna traction. Otoscopic examination shows erythema, edematous canal with debris. Canal edema prevents visualization of TM. Tenderness reported when palpation right pre and post auricular nodes. P: Medications: Rx: Oflaxcin solution Ofloxacin solution 5 drops (0.25mL) q12h for 7 days. Disp: #1 (One) 5mL bottle, no refills (Wirfs, 2017). Rx: Acetaminophen Acetaminophen 160mg/5ml. Sig: 7.5mL PO q6h PRN pain. Dispense 120mL, no refills (Epocrates, 2016). Ofloxacin and ciprofloxacin/ dexamethasone (Ciprodex) are approved for middle ear use and should be used if the tympanic membrane is not intact or its status cannot be determined visually (Schaefer & Baugh, 2012). Pain is a common symptom of acute otitis externa, and can be debilitating. First-line analgesics include nonsteroidal anti-inflammatory drugs and acetaminophen. Oral analgesics are the preferred treatment. Additional diagnostic tests: None at this time (Hollier, 2016).
Soc Hx: Attends half day K4 program, is doing well, and likes going to school. Always wears seatbelt. Fam Hx: Patient lives at home with parents, grandparents, and 3 siblings. ROS: Constitutional: Denies weight loss, fever, chills, weakness or fatigue. Has had a cold. HEENT: Denies any headaches or dizziness. Denies any changes in vision. Denies hearing loss or ringing in the ears, reports feeling a stabbing pain in his ear. Denies nasal congestion and discharge. Denies any sore throat or difficulty swallowing. Denies enlarged lymph nodes. Cardiovascular: Denies chest pain or discomfort. No reported palpitations. No reported cardiac history. Respiratory: Denies cough, difficulty breathing, and shortness of breath or wheezing. Gastrointestinal: Denies any abdominal pain or changes in bowels. Lymphatics: Denies any enlarged lymph nodes. No reported lymph node tenderness or neck stiffness. O: Vital signs: BP 102/60, Temp 99.9, P 94, RR 18, O2 Sat 99%, Height: 3’5” Weight: 37.5 lbs BMI: 15.7 (Underweight) General: Patient is alert, talkative, and is cooperative. HEENT: Normocephalic, hair thick and distributed throughout entire scalp. Conjunctiva clear, non-icteric, PERRLA, EOM’s intact. Right ear: tympanic membrane intact with light reflex noted. Left ear: tympanic membranes intact, red and bulging. No drainage noted in canal. Pinna/tragus w/o tenderness bilaterally. Nares patent, unremarkable bilaterally. Pharynx with clear drainage noted, tonsils 2/4 bilaterally. No loose teeth. Cardiovascular: Heart RRR w/o murmur. Respiratory: Lungs are clear to auscultation bilaterally. Respirations are unlabored/ Gastrointestinal: Abdomen slightly rounded with active bowel sounds in all 4 quadrants, soft, non-tender, no masses or organomegaly. Neck/Lymphatics: Neck supple. Thyroid midline, small, firm. Lymphadenopathy noted in preauricular and posterior cervical nodes, non-tender. Testing results: NA
A:
Left Acute Otitis Media (ICD 10-H66.92): Sudden onset of ear pain with a middle ear infection, erythema with moderate to severe bulging of the tympanic membrane, or a new onset of otorrhea. Usually a complication from a bacterial infection of the nasopharyngeal that follows the dysfunction of the Eustachian tube causing a buildup of bacteria, most commonly Streptococcus pneumoniae, Haemoophilus influenza, and Moraxella catarrhalis (Harmes et al, 2013). Signs and symptoms include; moderate to severe otalgia, irritability, erythema of TM, decreased TM mobility, distorted landmarks, displaced light reflex, cloudy/dull/opaque/bulging TM, fever >102.2F, N/V, diminished hearing, and dizziness (Hollier, 2016). Paddy is presenting with ear pain, stuffy and popping feeling in ears, and recent history of a cold as per mother. Pain is reported 3/5 on Wong Baker scale along with ear pain, a popping/stuffy feeling, and a stabbing pain in ear as per patient. Left ear TM are intact, red and bulging. Pharynx with clear drainage noted, tonsils 2/4 bilaterally. Lymphadenopathy noted in pre-auricular and posterior cervical nodes, non-tender. P: Medications: Rx: Amoxicillin 400mg/5mL Sig: 8.5mL oral suspension PO q12h x 10 days. Disp: 170mL oral suspension. No refills (Epocrates, 2017). Rx: Acetaminophen 160mg/5mL Sig: 7.5mL oral suspension PO q6h PRN pain. Disp: 120mL. No refills. (Epocrates, 2016). Additional diagnostic tests: None at this time (Hollier, 2016). Education: Take full course of antibiotics, even if symptoms resolve (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Swimming should be avoided until the infection clears, and avoid submersion (Dunphy, Winland-Brown, Porter, & Thomas, 2015). The ear canal should be kept as dry as possible (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Tympanic membrane perforation can be avoided by not using cotton swabs or sharp objects to clean ears (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Blowing of the nose should be avoided if possible (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Family members should be encouraged to stop smoking (Dunphy, Winland-Brown, Porter, & Thomas, 2015).
