SUBJECTIVE:20 year-old Samantha presents to the office with complaint of sore throat for 2 days. She has intermittent fever and her maximum temperature at home was 101.0 F (oral). Samantha complains that she has pain when she swallows. She also complains of a headache. Both the throat pain and headache are relieved slightly with the use of OTC pain relievers.
ROS: Denies no vomiting or diarrhea, rhinorrhea, cough, drooling or difficulty breathing
Diet: Normally has a balanced diet. Her appetite has decreased over the past 2 days since the throat pain began.
Elimination: She is voiding well with no complaints of dysuria
Sleep: Sleep has been interrupted from the pain in her throat Past medical history: Denies CA, HTN, DM, hypo/hyperthyroidFamily history: Mother history of hypothyroidism, father is healthy and no chronic issues. MGM died of emphysema
Social history: Currently in her second year of college. Does occasionally drink, denies smoking
Medications: OTC as needed for aches and pains, but otherwise not medications being taking regularly
Allergies: NKDA, up-to-date with immunizations HPV
OBJECTIVE: General: Alert, quiet and cooperative, appears well hydrated, acutely ill appearing
Vital signs: BP right arm sitting: 115/80, Temp 98.8 orally, RR 18, 1201bs, HR 74
HEENT: Normocephalic; Red reflexes are present bilaterally; PERRLA, no ocular discharge, external ear WNL, TM’s are gray and intact, no fluid evident behind TM’s bilaterally. Both nostrils are patent. There is no nasal discharge and no nasal flaring. Mucous membranes are moist. Both tonsils are erythematous and inflamed, +3. There are exudates present bilaterally, as well as palatal petechiae.
Neck: Supple and able to move in all directions without resistance; tender anterior and posterior cervical nodes present on both sides. No erythema of the nodes. Respiratory: Lungs are clear to auscultation in all lobes. There is good air entry.
Cardiac: S1/S2 present, no murmurs, regular rate and rhythm.
Abdomen: Normoactive bowel sounds were present throughout; soft and non-tender; no evidence of hepatosplenomegaly. Neurological: Good tone in all extremities; extremities warm and well-perfused. Cap refill is less than 2 seconds.
Musculoskeletal: Full range of motion of all extremities;
Answer the following questions for the Case Study above
Study Treatment Plan
Reflect on the case study; discuss the following criteria as part of that reflection.
- Introduction: Reflect on the case study; answer the following questions as part of that reflection. Introduce your paper including a brief description of your paper. Describe the purpose and plan for this paper.
- Subjective: What additional subjective information do you need from the patient?
- Objective: What additional physical exam findings are needed?
- Assessment: What additional history (past medical, surgical and family) exam findings are needed.
- Diagnosis(s) What is the most appropriate diagnosis(s) given the patient’s presentation. (include two differential diagnosis and ICD-10 codes)
- Assessment Findings: Include rationales based on your assessment findings to support your diagnosis(s).
- Plan: What labs and/or diagnostic testing, if any would you order? Please include CPT/Procedural codes for each.
- Referrals & Patient Education: Based on your patient’s given diagnosis, include referrals when applicable (if no referrals are necessary please state your reasons why and list pertinent patient education that is applicable to your diagnosis(s). Lastly, include return to clinical guidelines as part of your patient education.
- Prescriptions: Include written prescriptions of all medications that include prescriptions, OTC, (over the counter) and Herbal formulations; include teaching points with common potential side effects. Utilize the script padPreview the document for each medication.
- Summary: Explain how this paper met the purpose stated in the introduction.
Sample Solution
