NURSING 6512 Nursing 6512 - Week 5 Discussion.docx
SUBJECTIVE
Chief Complaint (CC): Sore throat for three days accompanied with decreased appetite,
... [Show More] headache and pain with swallowing.
History of Present Illness (HPI): Ms. L, a 20-year-old Hispanic female currently enrolled in a community college reports to the clinic with complaints of sore throat for three days accompanied with decreased appetite, headache and pain with swallowing. A runny nose has also been observed as well with hoarseness in her voice but doesn’t seem to sound congested. She reports that over the past few weeks there has been an outbreak of flu-like symptoms on her college campus. She has taken Ibuprofen for her headache and lozenges for her sore throat, but nothing seems to be alleviating her symptoms.
Location: Throat Onset: 3 days ago Character: Sore throat
Associated S/S: decreased appetite, pain with swallowing and headache
Timing: Two weeks after a flu-like symptom outbreak on college campus
Exacerbating/alleviating factors: Ibuprofen assists some, along with cooling beverages and cough drops
Severity: 8/10 pain scale
Current Medications: Ibuprofen 800mg every 4-6 hours as needed x3 days, cough drops 1 tab every 2-4 hours x3 days.
Allergies: No known allergies
Past Medical History (PMHx): Immunizations are up to date, flu shot November 2018, last tetanus April 2018. No significant illnesses or surgeries reported. Has never been hospitalized, denies any accidents or injuries and no history of blood transfusions.
Social History: Ms. L was born in West Virginia and currently attends Eastern West Virginia Community and Technical College for her bachelor’s degree in nursing. She does not stay on campus. She does drive back and forth to the local hospital where she works as a certified nursing assistant.
She reports the use of seatbelt while driving and does not text while operating that vehicle. She is in a long-term relationship, heterosexual and is sexually active. She uses contraceptives and has never been pregnant. She exercises 3-4 times/wk when not working or completely homework. Has never smoked, occasional alcohol use (3 mixed drinks/wk) but denies the use of illicit drugs. Great support system in her parents and 3 older siblings.
Family Medical History:
ARDS
Father age 68, acute Pancreatitis s/p cholecystectomy & HTN Mother age 71, HTN & DM2
Siblings: 2 brothers and 1 sister, all healthy with no history Paternal Grandmother: deceased at 85 due to acute lung injury s/p
Paternal Grandfather: deceased at 87 due to MI Maternal Grandmother: 94, living, hx DM2, HTN, CVA Maternal Grandfather: deceased at 63 due to MI
Review of Systems:
Gen: No unexplained weight loss or gain, + for decreased appetite, no chills,
+ fever, no fatigue
HEENT: No blurred vision or loss of vision, no loss of hearing, hearing difficulty or ringing in ears, no congestion, + for runny nose, sore throat and hoarseness.
Skin: No changes in skin such as rashes, dryness or persistent itching Respiratory: No SOB, wheezing, cough or sputum production Cardiovascular: No chest pain, palpitations, or extremity edema, no pain with walking
Gastrointestinal: No change in bowel habits, indigestions, nausea/vomiting or diarrhea. No abdominal pain or tenderness. + for decrease in appetite.
Genitourinary: No burning with urination, no itching. Last menstrual cycle 4/20/2018
Neurological: No dizziness, LOC, + headaches. Moves all extremities without tremors
Psychiatric: No mental illness, depression or anxiety Musculoskeletal: No muscular or joint pain Hematologic: No anemia, bleeding, not easily bruised
Lymphatics: No swelling/tenderness in lymph nodes, no history of splenectomy.
Endocrinological: No heat or cold intolerances, no sweating, no polyuria or polydipsia.
OBJECTIVE
Vital Signs: Ht. 5’4” Wt. 132lbs, BMI = 22.7, T-max 99.6, BP 116/74, pulse 65, respirations 16, o2 saturation 96% on RA.
Physical Exam:
HEENT: PERRLA, ears clear, nasal tenderness with drainage & slight redness, throat red with tenderness & exudate, hoarseness in voice. Tonsils enlarged, neck with no lymphadenopathy.
Skin: No rashes or itching
Resp: lungs CTA bilaterally, no cough or sputum production
Cardio: RRR without murmur or gallop Abdomen: Soft, nontender, BS + x4 GU: No abnormalities
Extremities: No edema, pulses palpable, moves all extremities without tremors
Neuro: AOx3, no focal deficits, no seizures
Psych: calm, cooperative, appreciate
Diagnostics: CBC/CMP, rapid strep with rapid influenza testing
ASSESSMENT
Differential Diagnoses:
Influenza: Flu, or influenza, is an infectious respiratory disease caused by a few flu infections that taint the nose, throat and lungs (National Institute of Allergy and Infectious Diseases, 2017). Influenza is a respiratory virus whose symptoms include a cough, sore throat, chills & fever
(Lewis, Dirksen, Heitkemper, & Bucher, 2014). Patient is displaying exemplary indications of sore throat, fever, migraine, and nasal drainage (Ball, Dains, Flynn, Solomon, and Stewart, 2015), with presentation to different irresistible sources on her school grounds, this condition might be likely pending diagnostics.
Group A streptococcal pharyngitis: I would also consider this because of her sore throat and enlarged tonsils, exudates on the tonsils, and negative for cough (Ball, Dains, Flynn, Solomon, and Stewart, 2015).
Laryngitis: Symptoms of laryngitis can start all of a sudden and generally deteriorate over a time of a few days. Manifestations incorporate dryness, trouble talking, sore throat, low grade fever and a steady need to clear throat (NHS, 2018).
Acute Pharyngitis: Infection of tonsils, sore throat, fever, red and swollen tonsils (Ball, Dains, Flynn, Solomon, and Stewart, 2015).
PLAN
Patient is instructed to avoid contact with any other individual until she is afebrile for 24 hours. Instructed to continue with Ibuprofen, throat lozenges, drink plenty of fluids and rest. If her symptoms do no clear or gets worse, she may need to be treated with antivirals to decrease symptoms and severity of the illness.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W. (2015).
Seidel's guide to physical
examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L. (2014). Medical- Surgical
Nursing: Assessment and management of clinical problems. St. Louis,
MO:
Elsevier.
National Institute of Allergy and Infectious Disease. (2017). Influenza.
Retrieved from
https://www.niaid.nih.gov/diseases-conditions/influenza
NHS. (2017). Retrieved from: https://www.nhsinform.scot/illnesses-and- conditions/ears-nose-and
throat/laryngitis#introduction [Show Less]