Primary Health of Acute Clients/Families Across the Lifespan

Soap Note

FNP 593: Primary Health of Acute Clients/Families Across the Lifespan

Don't use plagiarized sources. Get Your Custom Essay on
Primary Health of Acute Clients/Families Across the Lifespan
Just from $8 /Page 0r 300 words
Order Now

United States University

Save your time - order a paper!

Get your paper written from scratch within the tight deadline. Our service is a reliable solution to all your troubles. Place an order on any task and we will take care of it. You won’t have to worry about the quality and deadlines

Order Paper Now

This study source was downloaded by 100000784347808 from CourseHero.com on 05-05-2022 15:03:44 GMT -05:00

https://www.coursehero.com/file/133558470/Soap-1-FNP594docx/

 

 

Soap Note #7

Patient ID: JS Client’s Initials: RH Age: 27 Race: African American Gender: Female Date of Birth: 1/4/1995 Insurance: BC/BS Marital Status: Married

Subjective:

CC: “I have a cough, runny nose, and fever and tested positive for COVID-19 on 1/1/2022, I am still coughing and have congestion”

HPI: JS is an African American female, a reliable historian who presents to the clinic unaccompanied, complaining of a productive cough, sore throat, headache, runny nose since 12/28/2022 and tested positive for COVID-19 on 1/1/2022. She has been using Dayquil and NyQuil to control symptoms. She complains of a worsening cough and continued nasal congestion, she does not have a fever today but at home temperature had gotten as high as 102.7 degrees. She complains of night sweats and also has headache pain that she rates 5/10 relieved by Advil. Denies sick contacts or recent travel. Denies seasonal allergies

Past Medical History: None

Vaccinations: All Vaccines Current TDAP (2020), COVID19 (10/2021) Pfizer x 2 doses, influenza vaccine (2021), Eye exam 2021, Pap smear 2021.

Surgeries: None Hospitalizations: none

Allergies: NKA

Medications: Dayquil-4 times a day Nyquil- pm only Advil as needed for headache

Family History: Mother 53-no medical history Father: unknown

Social History: denies smoking, illicit drug use, or alcohol use

This study source was downloaded by 100000784347808 from CourseHero.com on 05-05-2022 15:03:44 GMT -05:00

https://www.coursehero.com/file/133558470/Soap-1-FNP594docx/

 

 

Other: Lives at home with wife and daughter

ROS: General: Admits to fever 102.7, weakness and fatigue. Denies weight change Eyes: Denies vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred vision, or blindness. Head: Admits to headaches 5/10. Denies lightheadedness, or dizziness. Eyes: Denies vision changes, diplopia, tearing, and scotomata, Ears: Denies tinnitus, vertigo, discharge, or earache. Nose: Admits to nasal congestion, drainage, itching, sneezing. Denies nosebleeds. Throat: Admits to sore throat. Denies difficulty swallowing. Last Dental exam 2020 C/V: Denies chest pain, palpitations. Pulmonary: Admits to productive Cough. Denies hemoptysis, dyspnea, wheezing, pleuritic pain Neuro: Admits to headache. Denies dizziness, focal numbness/weakness, nausea, vomiting. Lymph: Denies swollen lymph nodes in neck. Allergy/immunology: Denies seasonal allergies and frequent illness.

Objective Vital Signs: HR 898 BP 127/74 Temp 100.2 RR 18 SpO2 97% Pain 5/10

Height 66 in Weight 142 BMI: 24.8

Labs 7/09/21: HbA1c 5.5, LDL 50, HDL 49, Choles 97, TG 68, GFR 110, Physical Exam

General Survey: Well-groomed, well-nourished, cooperative reliable historian, dressed appropriately for the weather in no acute distress HEENT Ears: pinna clean, no exudate noted. TM intact and pearly gray with cone of light bilat. Nose: nasal mucosa pink and moist. Inferior turbinates slightly reddened bilat. Nares patent bilat. No sinus pain upon palpation. Septum midline. Throat: oral mucosa erythemic, tongue mobile without lesions, tonsils absent. Posterior pharynx with erythema but no cobblestone appearance. Neck: non-tender cervical area, no lymph nodes palpable. Non-enlarged thyroid palpated. Trachea midline.

This study source was downloaded by 100000784347808 from CourseHero.com on 05-05-2022 15:03:44 GMT -05:00

https://www.coursehero.com/file/133558470/Soap-1-FNP594docx/

 

 

Neuro: Alert and oriented x 4. Cardio: RRR. Crisp S1 S2 without clicks or murmurs. Thorax: Thorax is symmetric with good expansion. Respirations are even and unlabored. No use of accessory muscles, stridor, grunting, or nasal flaring. Lungs: Wheezing and congestion Bilaterally

Assessment

DX: COVID-19 Pneumonia (UO7.1) 1. COVID-19 Pneumonia most likely diagnosis as evidenced by symptoms and duration 2. Viral Pharyngitis-Not likely as the patient tested Positive for COVID-19 3. Allergic Rhinitis-Not likely as the patient does not have seasonal allergies

 

Plan

DX: COVID-19 Pneumonia (UO7.1) A: Observe appearance, negative for cyanosis, Monitor spO2, 97%, Wheezing and congested lung sounds B. Treat symptoms with antipyretics and cough medicine, increase fluids C: Azithromycin 250mg BID x 5 days, Decadron 6mg x 5 days E. Patient to go to Emergency Department for worsening symptoms or if spO2 drops below 92%. (Mikkelsen & Abramoff, 2021).

2: Viral Pharyngitis (J02.9) A: History and Physical examination, B: Topical antibiotic or Oral, Augmentin or Cephalexin C: Oral, Augmentin or Cephalexin D. Patient to return if signs and symptoms persist or worsen or if new symptoms develop (Cash, 2021, p. 170-172)

3: Allergic Rhinitis (J30.1) A: No diagnostic test done

B: Antihistamine, allergy testing and allergy shots if indicated C: Education on importance of adhering to medication regime D. Return to if symptoms persist or worsen, or if new symptoms develop, (Cash 2021, p. 153-156)

This study source was downloaded by 100000784347808 from CourseHero.com on 05-05-2022 15:03:44 GMT -05:00

https://www.coursehero.com/file/133558470/Soap-1-FNP594docx/

 

 

References

Cash, J. C., Glass, C. A., & Mullen, J. (2021). Family practice guidelines (5th ed.). Springer

Publishing Company.

Looking for a similar assignment? Get help from our qualified experts!

Order Now