Amanda Wheaton’s (AW) chief complaint for this visit is a sore throat. This symptom is
typically associated with an infection. I asked questions to
... [Show More] expand on and clarify the patient’s
history of her present illness (HPI) while focusing on a hypothesis of either upper or lower
respiratory infections. The questions asked are based on onset, location, duration, character,
aggravating and alleviating factors, radiation, and timing of her symptoms (Bickley & Szilagyi,
2017). Redundant questions were eliminated to increase efficiency. Questions regarding
potential associated symptoms were included to rule out different hypotheses.
Immunization status, contacts with unwell individuals, and sexual activities help
determine potential sources of infection without premature closure onto the wrong diagnosis
(Bickley & Szilagyi, 2017). The review of systems (ROS) questions were personalized based on
information from the HPI. This information continued to point toward an infection of the upper
respiratory tract. The ROS questions were focused on related systems, used to rule out
systemic versus localized involvement, and determine the severity of each system's
involvement.
Allergies and current medications determine what medications AW can take to treat her
ailment. Any medications prescribed must not have drug-to-drug interactions with any current
medications or illicit a potentially fatal allergic reaction from the patient. The history and ROS
questions' goals are to begin the search for a probable cause (Bickley & Szilagyi, 2017) and set
up a plan of care. Some maintenance health questions were missed. Knowledge gained from
these questions can affect treatment options.
An expanded problem-focused exam was performed because AW is an established
patient (Bickley & Szilagyi, 2017). An expanded problem-focused exam involves assessing the
body area involving the chief complaint and all associated organ systems (University of
Phoenix, 2018). Absence of cough, complaint of sore throat and swollen "neck glands,"
headache, presence of fever, and sick roommate are suggestive of group A beta-hemolytic [Show Less]