Hi I need a response to bellow peer’s soap note
Peer 1 A
Patient Name: J.C.
Age: 9 y/o.
Race: Hispanic.
Insurance: Medicaid.
Subjective data:
Chief complaint: ―My son has sore throat since 1 day ago”.
HPI: Scholar 9-year-old male with a history of health, Hispanic race, goes to the office
accompanied by his mother today; referring her son has sore throat, no fever and little pain. The
mother denies hi having taken medication and his physiological needs are normal. The symptoms
start one day ago. Sleep well and eat well too.
PMH: None
PFH: Mother: HTN. Father: DM.
Allergies: NKDA
Diet: Regular
Smoking: none
Alcohol: Denies
Drugs: Denies
Exercise: None.
Immunization:
Vaccine 1
st dose 2th dose 3th dose
Hep B 01/20/2012 03/21/201
2
06/18/2012
DTaP 03/21/2012 06/18/201
2
08/15/2012
Hib 03/21/2012 06/18/201 08/15/2012
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2
PCV 03/21/2012 06/18/201
2
08/15/2012
IPV 03/21/2012 06/18/201
2
08/15/2012
Rotavir
us
03/21/2012 06/18/201
2
08/15/2012
Flu 08/15/2012 01/18/2020
Varicel
a
01/20/2013
MMR 05/10/2013
Mening
occocal
06/17/2016
Tdap
ROS:
Constitutional: Patient has a sore throat, denies cough; denies fever, sweating at night. No
chest pain, nausea or vomiting as per patient.
Head: denies headaches, lightheadedness, or dizziness. Norm configured, without
bruising, trauma, no signs of injury, performs flexion and extension movements well.
Eyes: Denies visual changes, eye pain, eye drainage, denies ocular sequestration.
Ears: denies pain or drainage from the ear, hearing loss or tinnitus.
Nose: denies runny nose, epistaxis, sinus pain, congestion.
Throat: red, no exudates, refers 2/10 pain, eat well.
INTEGUMENTARY: Denies skin rash, no wound, no change in a mole, no unusual
growth, no dry skin, no jaundice, no lesions, no bruising, and no bleeding.
HAIR: No hair loss no abnormalities.
NAILS: Denies nails abnormalities, no discoloration, mild nail clubbing, no cyanosis, no
longitudinal ridges.
NEUROLOGIC: Denies changes in LOC, denies history of tremors, seizure, weakness,
numbness, dizziness, headaches once a week, memory lapses or loss.
RESPIRATORY: No Cough; No sputum; No wheezing, no hemoptysis, no bronchitis, no
pneumonia, no TB history.
CARDIOVASCULAR: Denies chest pain, no palpitations, no orthopnea, no edema, no
claudication, no known murmurs, no history of cardiac disease.
GASTROINTESTINAL: No Abdominal pain, no bloating. no Constipation. no
flatulence, no nauseas, no vomit, no diarrhea, no changes on stools, no black tarry stools, no
(melena) red or bright rectal bleeding after defecation, poor appetite.
GENITOURINARY: Denies dysuria, frequency, urgency, hesitancy, incontinence,
nocturia, hematuria. Denies genital discharge, no abnormal bleeding.
MUSCULOSKELETAL: Denies any limitation in movements in upper or lower
extremities. No other joint pain, stiffness, swelling, or muscle plain.
PSYCHIATRIC: Claims getting irritable not able to go to the bathroom every day. Not
anxiety note or report from the parents, no depression, no mood swing, no sleep disturbances, no
hallucinations.
ENDOCRINE: No excessive sweating, no cold/hot intolerance, no hot flashes, no
abnormal thirst/ hunger/appetite, normal urinary habits.
HEMATOLOGIC/LYMPHATIC: Denies history of anemia, no bruising, no abnormal
bleeding, no swollen glands
OBJECTIVES:
VS:
BP- 110/80 mmhg
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HR-80 x mint,
RR-18 pm
Temp-98.9 oF.
O2sat-100 %
W: 51 kg,
BMI Pctil: 55 p.
Pain 2/10. Scale.
General: Cooperative, normal speech, obese, noted with SOB.
Neurologic: Awake, alert, and oriented x 3, able to follow commands and make aye
contacts, responsive to verbal and tactile stimuli.
HEENT: Normocephalic, atraumatic, PERRLA +, no nasal drainage noted. Has a sore
throat, pharynges area erythematosus no exudates, no pathological lesions.
Neck: Full ROM. No JVD, no bruits, no masses, thyroid gland visible and palpable.
Chest: Normal appearance, symmetric.
Abnormal Breath sound in all four quadrants. Upon auscultations presence of wheezing
and crackles noted. Pt has a productive cough, with white sputum.
CVS: S1 and S2 present. Regular rate and rhythm, no gallop and no murmur upon
auscultation, bilateral upper extremities edema 1+, peripheral pulses present, no cyanosis.
Abdomen: Soft no tenderness, no organomegaly, no palpable mass. Bowels sound
presents.
Extremities: Symmetric, full ROM in all extremities.
Skin: Normal appearance, no scar, warm and dry to touch. No visible lesions, normal skin
turgor.
Genitourinary: No pain in CVA, no lesions, no discharge noted.
DIAGNOSIS:
ICD 10: J02.9; Pharyngitis, or sore throat, is often caused by infection. Common
respiratory viruses account for most cases, and these are usually self-limited. Bacteria are also
important etiologic agents, and, when identified properly, may be treated with antibacterial,
resulting in decreased local symptoms and prevention of serious sequelae.
DDx:
ICD 10: J05.10: Epiglottitis is inflammation of the epiglottis—the flap at the base of the
tongue that prevents food entering the trachea (windpipe). Symptoms are usually rapid in onset
and include trouble swallowing which can result in drooling, changes to the voice, fever, and an
increased breathing rate.
ICD 10: J02.0, Streptococcal pharyngitis. is an infection of the back of the throat
including the tonsils caused by group A streptococcus (GAS). Common symptoms include fever,
sore throat, red tonsils, and enlarged lymph nodes in the neck
ICD 10: J39.1 Retropharyngeal abscess. is an abscess located in the tissues in the back of
the throat behind the posterior pharyngeal wall (the retropharyngeal space). Because RPAs
typically occur in deep tissue, they are difficult to diagnose by physical examination alone
PLAN of CARE:
– Ibuprofen 800 mg 1-tab q8hrs, per 2 weeks.
Lifestyle and home remedies:
Drink fluids. Fluids keep the throat moist and prevent dehydration. Avoid caffeine and
alcohol, which can dehydrate you.
Try comforting foods and beverage. Warm liquids — broth, caffeine-free tea or warm
water with honey — and cold treats such as ice pops can soothe a sore throat.
Gargle with saltwater. A saltwater gargle of 1/4 to 1/2 teaspoon (1.25 to 2.50 milliliters)
of table salt to 4 to 8 ounces (120 to 240 milliliters) of warm water can help soothe a sore throat.
Children older than 6 and adults can gargle the solution and then spit it out.
Humidify the air. Use a cool-air humidifier to eliminate dry air that may further irritate a
sore throat, being sure to clean the humidifier regularly so it doesn’t grow mold or bacteria. Or sit
for several minutes in a steamy bathroom.
Avoid irritants. Keep your home free from cigarette smoke and cleaning products that can
irritate the throat.
Follow up in 2 weeks.
Referral: No.
PEER 2 M
NAME: S.A
AGE: 17 years old
ETHNICITY: Black/African American
PRIMARY LANGUAGE: English
GENDER: Female
SOURCE: Information was obtained from the patient and mother
DATE OF ENCOUNTER: 10/29/2020
ALLERGIES: NKDA, NKA
BIRTH HX: Patient was born at 40 weeks via vaginal birth, mother denies any complications during or post birth. Mother also denies any developmental delay throughout patient’s life.
PAST MEDICAL HISTORY: Patient denies any past medical history
PAST SURGICAL HISTORY: Patient denies any past surgical history
IMMUNIZATIONS: Up to date
CURRENT MEDICATIONS: NONE
FAMILY HISTORY: Mother and Father are alive, with no known health concerns. Patient has 1younger sister, with no known medical illness. Maternal grandmother and Maternal grandfather are deceased of unknown causes. Paternal grandmother and Paternal grandfather are deceased of unknown causes.
SOCIAL HISTORY: Patient is a high school student in the 11th grade. Patient stated, “I exercise every day, jogging for 20 to 30 mins. Patient denies smoking cigarettes, cigar, or marijuana. Patient denies drinking alcohol or using of any illicit drugs.
SEXUAL ORIENTATION: Heterosexual
NUTRITIONAL HISTORY: “I try to eat three or four healthy meals a day as much as possible, with a healthy fruit snacks, or carrot sticks in between, I drink 4 to 6 bottles of water a day”.
SUBJECTIVE
CHIEF COMPLAINT: “My throat has been hurting me for the past 2 days.”
HISTORY OF PRESENT ILLNESS: 17-year-old African American female, came to the clinic accompanied by her mother. She presents to the clinic with complaints of discomfort of sore throat has begun 2 days ago with fever, chills, and generalized muscle weakness. She has also experienced some difficulty swallowing, especially with solid food. She has also been coughing since the previous night, but the sputum is clear. She has had no contact any that is sick and has no pet at home. She has used some OTC Advil and Theraflu tea with little relief.
REVIEW OF SYSTEMS: Sore throat, difficulty swallowing, fever, and weakness, Otherwise the ROS is unremarkable for the remaining systems.
CONSTITUTIONAL: Patient reports fever, and weakness. She denies weigh gain, weight loss, appetite changes.
NEUROLOGIC: Denies changes in mood, attention span, though processes, and speech. Denies any changes in orientation, and memory. Denies history of epilepsy or tremors.
HEENT: HEAD: Denies any headache or feelings of lightheadedness and dizziness. EYES: Denies blurred or double vision, visual changes, flashing lights, or twitching. EARS: Denies ringing, drainage, or sensations of fullness, vertigo, earaches, ear discharge, or decreased in hearing acuity. NOSE: Denies any drainage or congestion. THROAT: Patient report sore throat and cough for the past 2 days.
NECK: Patient denies any neck pain or discomfort
CARDIOVASCULAR: Denies chest pain, paroxysmal nocturnal dyspnea, and palpitations., but has a history of HTN, and Hyperlipidemia.
RESPIRATORY: Denies any cough, SOB at rest or on exertion, pain with deep breathing, abnormal breath sounds, or abnormal discoloration of sputum. She reports sore throat and occasional coughing.
BREASTS: Denies any pain, dimpling, discharge, or abnormalities on the breasts. Perform breast self-examination monthly.
GASTROINTESTINAL: Denies any abnormalities such as nausea, vomiting, diarrhea, blood in stool, or changes in stool color. Pt denies abdominal pain, food intolerance, excessive belching, hiccupping, trouble swallowing, flatulence, or belching. Reports at least one bowel movements per day.
GENITOURINARY: Patient denies any urinary urgency, burning, pain and discomfort during urination. Patient denies any decrease in urinary output, or vaginal discharge. Pt denies any suprapubic pain.
GYN: First menarche at the age of 11, her period usually last 4 to 5 days
PERIPHERAL VASCULAR: Denies history of peripheral vascular disorders. Denies leg pain Denies history of blood clots, discoloration, and leg swelling.
MUSCULOSKELETAL: Pt denies limited ROM in upper and lower extremity joints. Pt denies any backache or stiffness in upper or lower extremities. Denies history of falls, contraction, fractures, or muscle weakness
INTEGUMENTARY: Denies any lesions, open wounds or cuts noted. Denies changes in hair or nail growth. Denies change in color, itching, dryness, and peeling of skin.
OBJECTIVE
Physical examination:
VITAL SIGNS: BP 110/70, HR 60, Temp. 98.0, O2 saturation 99% on room air, Resp. 16
Height: 5’2, Weight: 118 lbs., BMI 21.6, BMI-for-age at the 58th percentile for girls aged 17 years, pain: 4/10
GENERAL APPEARANCE: Patient is alert, oriented X4. No acute distress noted. She Appears well nourished, well-groomed, and appropriate for setting. Maintains eye contact and appropriate posture during health interview and examination. Pt is not currently experienced any fever currently as proven by temp 98.0, Pt report discomfort while swallowing.
NEUROLOGIC: Patient is AAOx4. Patient is calm and cooperative. Neurological status is grossly intact, Speech is clear and coherent. No change in sensation. Gait even and steady. Cranial nerves II-XII are intact.
INTEGUMENTARY: Warm, moisture, intact, no lesions, ulcers, rash, wound, sores. jaundice, or cyanosis noted. Brisk skin turgor. No masses noted.
NAILS: No nails discoloration, no clubbing, no cyanosis, brittleness, or another deformity noted, capillary refill less than 3 seconds.
HAIR: Evenly distributed in the proper areas, no abnormality was noted or reported.
HEENT: HEAD: Normocephalic with no lumps, cuts, or bruises noted. EYES: Symmetrical. PERRLA. Conjunctiva pink, Sclera white, vision is 20/20 bilaterally. EARS: Normal hearing acuity. External ears intact. No drainage noted. Tympanic membrane is pearly grey and translucent. NOSE: Nasal septum at midline, no drainage noted. Mucosa is pink and moist. No sinus tenderness. THROAT/MOUTH: Mucous membranes and tongue are moist pink and intact, no foul odor or lesion noted, but bilateral tonsillar enlargement and erythematous noted
NECK: Trachea midline, neck supple, no goiter. No Stiffness, and no limitation ROM noted on extension, flexion, and rotation. No JVD. No carotid bruits auscultated. Submandibular nodes painful on palpation
RESPIRATORY: Respiration is effortless, Symmetrical chest expansion. Right and Left lung fields are clear during auscultation.
CARDIOVASCULAR: No murmur, No Present of S3 or S4 on auscultation. PMI located at 5th intercostal space at mid clavicle line, towards the left, S1 and S2 present with no change. No rubs, no bruit. No JVD. No Peripheral edema. Denied claudication or pain.
BREASTS: No tenderness, dimpling, masses, asymmetry, nipple discharge, deviation, or axillary swollen lymph nodes.
GASTROINTESTINAL: Abdomen is soft, no scarring, distention, and pulsating mass noted. No bruits. Bowel sounds present in all 4 quadrants. Tympany heard throughout upon percussion No masses, costovertebral angle tenderness, hepatomegaly, or splenomegaly. No rebound tenderness or guarding noted.
GENITOURINARY/GENITALIA: Patient denies dysuria, burning, frequency, urgency of urination. She denies any discharge or hematuria. No CVA Tenderness. Pt denies no redness, irritation, or abnormal bleeding.
GENITALIA: Deferred
MUSCULOSKELETAL: Patients reports 3 days of intermittent lower back pain. Patient denied any history of fall, contractures, fractures, or joint pain. Full range of motion and motor strength of all joints: 5/5 and reflexes: 2+ throughout. Pulses are equally perceived throughout. Cranial nerves II-XII grossly intact. Intact gross sensorium, normal gait, and negative Romberg sign.
ENDOCRINE: No excessive sweating, no cold or heat intolerance, no report of abnormal changes to thirst, hunger, appetite.
PSYCHIATRIC: patient does not appear anxious. She is calm and cooperative and answer all questions properly. Patient denied having any feelings of depression, irritability, mood swing, sleep disturbances, hallucinations, or thoughts of suicidal or homicidal ideation.
LYMPHATIC/HEMATOLOGIC: No erythema, ecchymosis, swollen and tender lymph nodes noted.
Diagnosis:
1. Streptococcal pharyngitis (ICD J02.0)
Rationale: This patient has been experiencing fever, discomfort on swallowing consistent with the tonsillar enlargement noted on physical examination. On physical examination her throat is erythematous but there are no secretions on the pharyngeal walls. Based on the chief complaints, and physical examination this diagnose was made. According CDC (2020) Strep Pharyngitis is an infection of the Oropharynx cause by the S. pyogenes. S. pyogenes are gram-positive cocci. The patient with infection most often exhibits symptoms of sore throat, fever, and on examination Pharyngeal and tonsillar erythema, and Tonsillar hypertrophy with or without exudates (CDC 2020). The diagnosis chosen was supported by these findings.
Differential Diagnoses:
1. Acute tonsillitis Unspecified (ICD J03.90) According Mayo Clinic (2018) this infection can be cause by either viral or bacterial infections. A patient who is diagnose with is illness, most often complains of sore throat, swollen tonsils, difficulty swallowing, enlarge and painful lymph nodes and during examination a white or yellow coating or patches are usually visualized on the tonsils and stiff neck ( Mayo Clinic 2018). With tonsillitis prompt diagnose is imperative, so to initiate the proper treatment, to prevent any complications from occurring (Mayo Clinic 2018). If treatment is not effective, surgical intervention will most likely occur, to avert further severe health problems. This diagnosis mimics some of the symptoms Miss S. A. is experiencing, but it can be ruled out because no white or yellow coating was noted on the tonsils and she denies having stiff neck.
2. Peritonsillar Abscess (ICD J36) Usually occurs because of untreated Tonsillitis of Strep throat. It is Commonly known as “Quinsy”, which is uncommon, but it is a complication of Tonsillitis (Galioto 2017). This particular diagnosis affects mainly young adults, can be a recurrent problem if not treated properly, and cause potential dangerous complications, such as airway obstruction, aspiration, or extension of infection into deep neck tissues, so initiating prompt intervention is imperative ( Galioto 2017). Peritonsillar abscess is considered a medical emergency and prompt intervention is necessary. This diagnose can be rules out on the basis of the symptoms reported and symptoms noted on physical examination, Miss S.A, did not experienced trismus, or speak in a muffled voice tone.
Patient Education and Plan of Care
CPT 85025 Blood Count; Complete CBC; Automated & Automated Differential WBC (CBC w/ differentials),
CPT 80053 Comprehensive Metabolic Panel (CMP)
CPT 87880 Infectious Agent, Immunoassay, Direct Observation, Streptococcus Group
CPT 3210F Group A Strep Test Performed
Medications:
– Z-pack as per instructions: 500 mg BID on first day, then qd. on the next four days.
– Ibuprofen 200- 400mg q8hrs x 5 days PRN with food
Education
- Take medication as prescribed
- Take full course of medication even if symptoms subside
- Wash hands-à hygiene
- Hydration is essential: Increase fluid intake.
- Increase vitamin C.
- Lifestyle modification, diet and exercise education completed
- Rest as much as possible.
- Return to the clinic or go to the nearest ED if symptoms worsen
- Follow-up appointment scheduled
- Report any new symptoms to the provider.
Anticipatory Guidance:
- Practice safe sex–>utilize condom
- Car safety–> wear seat belt
- Avoid driving in the car with some who have been drinking
- Do not drink and drive
- Avoid doing drug, Alcohol, smoking, secondhand smoking
- Gun safety
NAME: S.A
AGE: 17 years old
ETHNICITY: Black/African American
PRIMARY LANGUAGE: English
GENDER: Female
SOURCE: Information was obtained from the patient and mother
DATE OF ENCOUNTER: 10/29/2020
ALLERGIES: NKDA, NKA
BIRTH HX: Patient was born at 40 weeks via vaginal birth, mother denies any complications during or post birth. Mother also denies any developmental delay throughout patient’s life.
PAST MEDICAL HISTORY: Patient denies any past medical history
PAST SURGICAL HISTORY: Patient denies any past surgical history
IMMUNIZATIONS: Up to date
CURRENT MEDICATIONS: NONE
FAMILY HISTORY: Mother and Father are alive, with no known health concerns. Patient has 1younger sister, with no known medical illness. Maternal grandmother and Maternal grandfather are deceased of unknown causes. Paternal grandmother and Paternal grandfather are deceased of unknown causes.
SOCIAL HISTORY: Patient is a high school student in the 11th grade. Patient stated, “I exercise every day, jogging for 20 to 30 mins. Patient denies smoking cigarettes, cigar, or marijuana. Patient denies drinking alcohol or using of any illicit drugs.
SEXUAL ORIENTATION: Heterosexual
NUTRITIONAL HISTORY: “I try to eat three or four healthy meals a day as much as possible, with a healthy fruit snacks, or carrot sticks in between, I drink 4 to 6 bottles of water a day”.
SUBJECTIVE
CHIEF COMPLAINT: “My throat has been hurting me for the past 2 days.”
HISTORY OF PRESENT ILLNESS: 17-year-old African American female, came to the clinic accompanied by her mother. She presents to the clinic with complaints of discomfort of sore throat has begun 2 days ago with fever, chills, and generalized muscle weakness. She has also experienced some difficulty swallowing, especially with solid food. She has also been coughing since the previous night, but the sputum is clear. She has had no contact any that is sick and has no pet at home. She has used some OTC Advil and Theraflu tea with little relief.
REVIEW OF SYSTEMS: Sore throat, difficulty swallowing, fever, and weakness, Otherwise the ROS is unremarkable for the remaining systems.
CONSTITUTIONAL: Patient reports fever, and weakness. She denies weigh gain, weight loss, appetite changes.
NEUROLOGIC: Denies changes in mood, attention span, though processes, and speech. Denies any changes in orientation, and memory. Denies history of epilepsy or tremors.
HEENT: HEAD: Denies any headache or feelings of lightheadedness and dizziness. EYES: Denies blurred or double vision, visual changes, flashing lights, or twitching. EARS: Denies ringing, drainage, or sensations of fullness, vertigo, earaches, ear discharge, or decreased in hearing acuity. NOSE: Denies any drainage or congestion. THROAT: Patient report sore throat and cough for the past 2 days.
NECK: Patient denies any neck pain or discomfort
CARDIOVASCULAR: Denies chest pain, paroxysmal nocturnal dyspnea, and palpitations., but has a history of HTN, and Hyperlipidemia.
RESPIRATORY: Denies any cough, SOB at rest or on exertion, pain with deep breathing, abnormal breath sounds, or abnormal discoloration of sputum. She reports sore throat and occasional coughing.
BREASTS: Denies any pain, dimpling, discharge, or abnormalities on the breasts. Perform breast self-examination monthly.
GASTROINTESTINAL: Denies any abnormalities such as nausea, vomiting, diarrhea, blood in stool, or changes in stool color. Pt denies abdominal pain, food intolerance, excessive belching, hiccupping, trouble swallowing, flatulence, or belching. Reports at least one bowel movements per day.
GENITOURINARY: Patient denies any urinary urgency, burning, pain and discomfort during urination. Patient denies any decrease in urinary output, or vaginal discharge. Pt denies any suprapubic pain.
GYN: First menarche at the age of 11, her period usually last 4 to 5 days
PERIPHERAL VASCULAR: Denies history of peripheral vascular disorders. Denies leg pain Denies history of blood clots, discoloration, and leg swelling.
MUSCULOSKELETAL: Pt denies limited ROM in upper and lower extremity joints. Pt denies any backache or stiffness in upper or lower extremities. Denies history of falls, contraction, fractures, or muscle weakness
INTEGUMENTARY: Denies any lesions, open wounds or cuts noted. Denies changes in hair or nail growth. Denies change in color, itching, dryness, and peeling of skin.
OBJECTIVE
Physical examination:
VITAL SIGNS: BP 110/70, HR 60, Temp. 98.0, O2 saturation 99% on room air, Resp. 16
Height: 5’2, Weight: 118 lbs., BMI 21.6, BMI-for-age at the 58th percentile for girls aged 17 years, pain: 4/10
GENERAL APPEARANCE: Patient is alert, oriented X4. No acute distress noted. She Appears well nourished, well-groomed, and appropriate for setting. Maintains eye contact and appropriate posture during health interview and examination. Pt is not currently experienced any fever currently as proven by temp 98.0, Pt report discomfort while swallowing.
NEUROLOGIC: Patient is AAOx4. Patient is calm and cooperative. Neurological status is grossly intact, Speech is clear and coherent. No change in sensation. Gait even and steady. Cranial nerves II-XII are intact.
INTEGUMENTARY: Warm, moisture, intact, no lesions, ulcers, rash, wound, sores. jaundice, or cyanosis noted. Brisk skin turgor. No masses noted.
NAILS: No nails discoloration, no clubbing, no cyanosis, brittleness, or another deformity noted, capillary refill less than 3 seconds.
HAIR: Evenly distributed in the proper areas, no abnormality was noted or reported.
HEENT: HEAD: Normocephalic with no lumps, cuts, or bruises noted. EYES: Symmetrical. PERRLA. Conjunctiva pink, Sclera white, vision is 20/20 bilaterally. EARS: Normal hearing acuity. External ears intact. No drainage noted. Tympanic membrane is pearly grey and translucent. NOSE: Nasal septum at midline, no drainage noted. Mucosa is pink and moist. No sinus tenderness. THROAT/MOUTH: Mucous membranes and tongue are moist pink and intact, no foul odor or lesion noted, but bilateral tonsillar enlargement and erythematous noted
NECK: Trachea midline, neck supple, no goiter. No Stiffness, and no limitation ROM noted on extension, flexion, and rotation. No JVD. No carotid bruits auscultated. Submandibular nodes painful on palpation
RESPIRATORY: Respiration is effortless, Symmetrical chest expansion. Right and Left lung fields are clear during auscultation.
CARDIOVASCULAR: No murmur, No Present of S3 or S4 on auscultation. PMI located at 5th intercostal space at mid clavicle line, towards the left, S1 and S2 present with no change. No rubs, no bruit. No JVD. No Peripheral edema. Denied claudication or pain.
BREASTS: No tenderness, dimpling, masses, asymmetry, nipple discharge, deviation, or axillary swollen lymph nodes.
GASTROINTESTINAL: Abdomen is soft, no scarring, distention, and pulsating mass noted. No bruits. Bowel sounds present in all 4 quadrants. Tympany heard throughout upon percussion No masses, costovertebral angle tenderness, hepatomegaly, or splenomegaly. No rebound tenderness or guarding noted.
GENITOURINARY/GENITALIA: Patient denies dysuria, burning, frequency, urgency of urination. She denies any discharge or hematuria. No CVA Tenderness. Pt denies no redness, irritation, or abnormal bleeding.
GENITALIA: Deferred
MUSCULOSKELETAL: Patients reports 3 days of intermittent lower back pain. Patient denied any history of fall, contractures, fractures, or joint pain. Full range of motion and motor strength of all joints: 5/5 and reflexes: 2+ throughout. Pulses are equally perceived throughout. Cranial nerves II-XII grossly intact. Intact gross sensorium, normal gait, and negative Romberg sign.
ENDOCRINE: No excessive sweating, no cold or heat intolerance, no report of abnormal changes to thirst, hunger, appetite.
PSYCHIATRIC: patient does not appear anxious. She is calm and cooperative and answer all questions properly. Patient denied having any feelings of depression, irritability, mood swing, sleep disturbances, hallucinations, or thoughts of suicidal or homicidal ideation.
LYMPHATIC/HEMATOLOGIC: No erythema, ecchymosis, swollen and tender lymph nodes noted.
Diagnosis:
1. Streptococcal pharyngitis (ICD J02.0)
Rationale: This patient has been experiencing fever, discomfort on swallowing consistent with the tonsillar enlargement noted on physical examination. On physical examination her throat is erythematous but there are no secretions on the pharyngeal walls. Based on the chief complaints, and physical examination this diagnose was made. According CDC (2020) Strep Pharyngitis is an infection of the Oropharynx cause by the S. pyogenes. S. pyogenes are gram-positive cocci. The patient with infection most often exhibits symptoms of sore throat, fever, and on examination Pharyngeal and tonsillar erythema, and Tonsillar hypertrophy with or without exudates (CDC 2020). The diagnosis chosen was supported by these findings.
Differential Diagnoses:
1. Acute tonsillitis Unspecified (ICD J03.90) According Mayo Clinic (2018) this infection can be cause by either viral or bacterial infections. A patient who is diagnose with is illness, most often complains of sore throat, swollen tonsils, difficulty swallowing, enlarge and painful lymph nodes and during examination a white or yellow coating or patches are usually visualized on the tonsils and stiff neck ( Mayo Clinic 2018). With tonsillitis prompt diagnose is imperative, so to initiate the proper treatment, to prevent any complications from occurring (Mayo Clinic 2018). If treatment is not effective, surgical intervention will most likely occur, to avert further severe health problems. This diagnosis mimics some of the symptoms Miss S. A. is experiencing, but it can be ruled out because no white or yellow coating was noted on the tonsils and she denies having stiff neck.
2. Peritonsillar Abscess (ICD J36) Usually occurs because of untreated Tonsillitis of Strep throat. It is Commonly known as “Quinsy”, which is uncommon, but it is a complication of Tonsillitis (Galioto 2017). This particular diagnosis affects mainly young adults, can be a recurrent problem if not treated properly, and cause potential dangerous complications, such as airway obstruction, aspiration, or extension of infection into deep neck tissues, so initiating prompt intervention is imperative ( Galioto 2017). Peritonsillar abscess is considered a medical emergency and prompt intervention is necessary. This diagnose can be rules out on the basis of the symptoms reported and symptoms noted on physical examination, Miss S.A, did not experienced trismus, or speak in a muffled voice tone.
Patient Education and Plan of Care
CPT 85025 Blood Count; Complete CBC; Automated & Automated Differential WBC (CBC w/ differentials),
CPT 80053 Comprehensive Metabolic Panel (CMP)
CPT 87880 Infectious Agent, Immunoassay, Direct Observation, Streptococcus Group
CPT 3210F Group A Strep Test Performed
Medications:
– Z-pack as per instructions: 500 mg BID on first day, then qd. on the next four days.
– Ibuprofen 200- 400mg q8hrs x 5 days PRN with food
Education
- Take medication as prescribed
- Take full course of medication even if symptoms subside
- Wash hands-à hygiene
- Hydration is essential: Increase fluid intake.
- Increase vitamin C.
- Lifestyle modification, diet and exercise education completed
- Rest as much as possible.
- Return to the clinic or go to the nearest ED if symptoms worsen
- Follow-up appointment scheduled
- Report any new symptoms to the provider.
Anticipatory Guidance:
- Practice safe sex–>utilize condom
- Car safety–> wear seat belt
- Avoid driving in the car with some who have been drinking
- Do not drink and drive
- Avoid doing drug, Alcohol, smoking, secondhand smoking
- Gun safety
