I Need ONE Response Per Each Discussion (soap note) Total 8 Responses. Attached Are The Discussions Posts Will Be A Minimum Of 100 Words, APA Format.One Reference Per Each Discussion
Soap Note 1
Age: 16 y/o Sex: Male
Allergies: Tobacco smoke, cold
SUBJECTIVE
CC: “Father: He has a wheezing cough that occurs when he is asleep, is out in the cold, or when he engages in physical exercise.”
HPI: A 16-year-old boy presents to the clinic accompanied by a father. The father reports that the patient was out playing with his friends on a cold and chilly morning when the attack occurred. He reports the patient has been having incidences of attack since he was 10-year-old and that the exacerbation continues even with Ventolin bronchodilator which offers a quick relief rescue inhaler that relieves the patient of the symptoms. The patient continued to experience wheezing and shortness of breath and on arrival, he could not speak clearly. The patient was put on intravenous 0025% w/v Atrovent to manage the attack. A chest X-ray was done on the patient. Patient’s last attack was more than a year ago. Has been on ephedrine treatment schedule which has been working effectively. He was barely responsive and had difficulty breathing and speaking. Onset: 8 hours ago Location: Respiratory system Duration: 7 years now Characteristics: Coughing, wheezing sound when breathing, shortness of breath, and chest congestion. Aggravating Factors: Cold, tobacco smoke, exercise Relieving Factors: being in warm weather, not exercising, and not inhaling tobacco smoke Treatment: intravenous 0025% w/v Atrovent, Ventolin bronchodilator, ephedrine
Current Medications: Xopenex
PMH Medication Intolerances: None Chronic Illnesses/Major traumas: No Screening Hx/Immunizations Hx: Up to date Hospitalizations: None Surgeries: None
Family History: Mother: Mother- Eczema, seasonal allergies, mild asthma Father: seasonal allergies Sister: eczema Allergies: Mother allergic to cold and dust
Social History: The boy attends a local school 5 days a week. Lives with both parents, two sisters, and an aunt.
ROS
General Denies fever, denies chills. Denies malaise, fatigue, and weakness.
Cardiovascular Reports airflow obstruction, reports severe dyspnea, cough, frothy sputum, rales, and wheezing.
Skin No change of coloration such as cyanosis or jaundice, no rashes or pruritus
Respiratory Patient reports shortness of breath, cough, and hemoptysis.
Eyes Deny any changes in vision, diplopia, or blurred vision.
Gastrointestinal Denies abdominal pain. Denies dysphagia (difficulty swallowing). Denies nausea, indigestion. Denies bowel irregularity and constipation.
Ears Reports no pain, no discharge.
Genitourinary/Gynecological Denies burning sensation while urinating. Denies a change in the color of urine, frequency, and urgency.
Nose/Mouth/Throat Reports no running nose, denies changes in sense of smell, denies nose bleeds. Nasal mucosa moist and pink membranes, nasal septum straight and midline.
Musculoskeletal Denies joint stiffness, restriction of motion. Denies swelling, redness, heat, bony deformity.
Head/Neck: Denies headaches, syncope. reports loss of consciousness while under attack, stiffness, masses, or pain. Denies neck stiffness.
Neurological Denies dizziness and weakness. Denies seizures or paralysis. Denies problems with sensation or coordination tremors.
Heme/Lymph/Endo Lymph node not palpable and no tenderness noted.
Psychiatric Not anxiety noted or reported from the parents, no depression, no irritability, no mood swing, no sleep disturbances, no hallucinations.
OBJECTIVE
Weight 15.9 kg BMI 19.3 Temp 96.5F BP: 92/63
Height 74.2cm Pulse 87 Resp:17
PHYSICAL EXAMINATION
General Appearance K.F is a 16-year-old boy with a well-developed body physique. No gait or posture abnormalities noted.
Skin: No injuries, lacerations, rashes, or bruises. The skin is pink, warm, no edema. Hair is well-groomed with even distribution.
HEENT Head: Head is normocephalic and atraumatic.
Eyes: pupils equal, round, and reactive to light and accommodation; extra-ocular motion intact; sinuses nontender; moist mucosa without lesions; no ocular injection; no keratoconus.
Ears: Left ear external redness and bulging TM, no effusion noted. Bony landmarks and light reflex noted bilaterally
Nose: Nasal mucosa moist and pink membranes, no postnasal drip, septum straight and midline. Throat/Mouth: Oral mucosa pink and moist. The posterior pharyngeal wall is moist and pink, without exudate.
Cardiovascular Pulse rate greater than 90 and greater than 110 beats per minute at rest, signifying the asthma exacerbation is severe and medical attention thus necessary.
Respiratory Auscultation and percussion indicate abnormalities; wheezing observable.
Gastrointestinal Soft, non-tender, normal bowel sounds; no hepatomegaly; no splenomegaly; no ascites.
Breast Breasts are normal in appearance and are well-anchored.
Genitourinary No pain or sensation of urinating. No change in the color of urine, frequency, and urgency.
Musculoskeletal Bilateral upper and lower extremities without swelling. No mass or deformities. No clubbing or cyanosis. The spine is aligned. Range of motion of spine and extremities intact. No joint erythema or tenderness. Normal muscular development. Normal gait.
Neurological CN II-XII; sensory, motor, cerebellum intact; DTRs 2+ and symmetric.
Psychiatric Normal, no signs or symptoms of depression, no anxiety, no suicidal ideas. No impairment of thought content. Able to demonstrate good judgment.
Lab Tests Exhaled nitric oxide
Special Tests: None
Diagnosis
1. Primary Diagnosis-
J45.901asthma exacerbation: Abdullah and Adel (2019) hold that asthma clinically recognized on the basis of progressive increase in shortness of breath, coughing, wheezing, chest tightness, and reduction in the functioning of the lungs. When these symptoms manifest, medical intervention is necessary. Exacerbation includes an increase in coughing when asleep, a decrease in exercise tolerance, impairment of daily activities, and an acute increase in wheezing and shortness of breath. The goal of therapy is to correct hypoxemia/hypercarbia and to rapidly reverse airflow obstruction. Indeed, preventing complications such as air leakage, promoting appropriate disposition of the patient, and reducing the possibility of recurrence by providing adequate baseline control therapies are a priority.
Differential Diagnoses
1. J18.9 Pneumonia, unspecified organism: Johnson and Abraham (2019) hold that patients undergoing diagnosis for asthma that refractory to treatment should be evaluated for alternative diagnoses including pneumonia whose symptoms include tachypnea, fever, and radiologic evidence of parenchymal infiltrates. It is initiated by the colonization of nasopharynx with subsequent infection of the lower respiratory tract caused by bacteria, viruses, or fungi. Symptoms could be improved by proton pump inhibitor therapy like GERD, although it could be ineffective for persistent asthma without GERD symptoms.
2. J32. 9 - Chronic sinusitis, unspecified: Ullmann and Mirra (2018) hold that sinusitis is essential to the differential of asthma. It exhibits respiratory symptoms similar to asthma including shortness of breath from extensive turbinate edema and cough from postnasal drip. Indeed, asthma exacerbation and chronic sinusitis chare many inflammatory mediators, which could be triggered by infections and air pollution, and allergens. Exposure to perennial allergens such as dust mite, mold, cold, tobacco smoke contributes to the chronicity of the disease. Intranasal corticosteroids are used in the treatment of allergic rhinitis. Amoxicillin is the first-line therapy for the condition.
3. T78. 2 - Anaphylactic Bidder (2019) posits that anaphylaxis is a systemic, potentially life-threatening, immediate reaction that is most commonly induced by allergy to medication or foods. It is basically a result of IgE-mediated mechanism that affects the cutaneous, respiratory, cardiovascular, and gastrointestinal systems. It resembles asthma if respiratory symptoms precede other organ system manifestations. Patients should be treated with prophylactic H1 and H2 antagonists for long-term control and in rare cases with corticosteroids. Epinephrine auto-injectors should be prescribed for anaphylaxis. The use of omalizumab as an anti-IgE antibody and rituximab is also recommended.
PLAN including education ·
Plan: The patient should:
Avoid cold weather;
Tobacco smoke; and
Aggressive physical exercise.
Treatments: Meds: Inhaled corticosteroids improve disease control and reduce asthma exacerbations. They reduce asthma exacerbations by 50%. A 10-day dose reduces the number of airway eosinophils that reflect enhanced inflammation with a respiratory infection. Asthmatic patients with intrinsic immune-logic abnormalities that show a higher risk of exacerbation by RV-infection would be treated with an anti-RV vaccine in advance. Sub-cutaneous epinephrine solution or terbutaline are used treatment of the condition. Nebulized ipratropium is co-administered with nebulized albuterol for patients who do not respond optimally to albuterol alone (Jamee & Stephen, 2017).
Diagnostic labs: None initially Procedures performed: Exhaled nitric oxide
Education— Parents are educated on the need to control allergens from the environment in which the patient is living include dust that could aggravate respiratory complications. Indeed, it is important to ensure that K.F does not engage get too cold and he stays away from strenuous physical exercise. K.F’s father who is a cigarette smoker should limit or even completely stop smoking when in the environment where the patient lives. It is important for the parents to ensure the environment at school does not expose the boy to more allergens which could worsen the risk for asthma exacerbations. Indeed, ozone, nitrogen dioxide, sulfur dioxide, and diesel exhaust increase airway inflammation and airway responsiveness. Airway pollutants, together with a viral infection, may act as synergies of asthma exacerbations (Jamee & Stephen, 2017). Four components of effective management of asthma exacerbations include education, monitoring of symptoms and lung function, controlling triggering factors and comorbid conditions, and pharmacologic therapy. It has been shown that patient education on asthma decreases exacerbations and improves control. Education to K.F’s parents is thus important in informing better management and control of the condition (Jamee & Stephen, 2017).
Referrals: None for the moment.
Follow-up: Return for reevaluation if symptoms persist.
REFERENCES
Abdullah, A., & Adel, S. (2019). Management of asthma exacerbation in the emergency departments, International Journal of Pediatrics & Adolescent Medicine, 6(2), 61-67. Bidder, M. (2019). Effective management of adult patients with asthma, Nursing Standard, 12(3), 3-14. Jamee, R., Stephen, P. (2017). Asthma Exacerbations: Pathogenesis, Prevention, and Treatment, Journal of Allergy Clinical Immunology Practice, 5(4), 918-923. Johnson, T., & Abraham, M. (2019). Differential diagnosis of Asthma, Allergy and Asthma, 2(1), 384-397. Ullmann, N., & Mirra, V. (2018). Asthma: Differential Diagnosis and Comorbidities, Frontiers in Pediatrics, 6(276), 2-8.
Soap Note 2
Subjective:
Chief Complaint: “I’m having runny nose and sore throat”.
HPI: A 15-year-old teenager, coming whit his mother, he said that he presents 2-day history of runny nose and sore throat. He feels hot and sweaty, has a mild headache, is coughing up clear sputum, and complains of muscle aches. He would like antibiotics as he had prescribed them last year for similar symptoms. On examination, he is afebrile and has a normal pulse, a slightly inflamed pharynx, and nontender cervical lymphadenopathy. There is no neck stiffness and his chest are clear. He has tried over-the-counter cough medications but has not found these helpful.
Allergies (Drug/Other): No. PMH: None.
PMHx: None. Hospitalizations: None. Current Meds: No.
Family Hx: No.
Parent’ Social history: Married Lives.
Other: Smoke No, ETOH No, Recreational Drug Use no. Description of milestones according to developmental age: Social/Emotional:
Teenager scholar has wonderful evaluation, practice sport, visit poll, cinema, has more Thant 20 friends, good interpersonal and familiar relations ship.
Language/Communication Speaking 2 languages.
Cognitive (learning, thinking, problem-solving)
Use technologies like telephone, computer, video games, etc. Movement/Physical Development
Visit gym, use cycle, walk different time per week. Emotional/Social Changes
Show more independence from parents and family. ROS:
General: No recent illness, no fever, no chills, no night sweats, refers itching in both hand and redness.
Head: No headache. Normo-configured, no scars, no previous injuries. No signs of injury perform 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: slightly inflamed pharynx.
Heart: Denies chest pain or palpitation. Tachycardia or bradycardia.
Respiratory: refers runny nose and sore throat. Denies changes in sputum. Some cough is present.
Gastrointestinal: denies nausea, vomiting, diarrhea, constipation, or any abdominal pain.
Patient reports having daily bowel movements.
Integumentary: Has a small lesion on both site of his neck, no lesion on extremities and hands. No abnormalities of hair or nails. Denies pain, denies prurito.
Hematologic/Lymphatic: denies bruising or bleeding, purpura, petechiae, prolonged or excessive bleeding.
Extremities: hands: refers itching and redness, no other symptoms. Inferior ext.: No alterations. Musculoskeletal: denies musculoskeletal pain, history of inflammation of the joints, arthritis.
Neurological: Alert, No history of neurological diseases, well oriented in space and person time, no Headaches, seizures, or involuntary movements, normal gait, normal language.
Objective:
Physical Exam:
GENERAL: Cooperative, normal speech, no distress noted. Denies Fever, Weight Loss or Weight Gain has well-nourished.
Vital signs:
Temperature: 97.0 oF RR: 16 x min
HR: 82 x min O2Sat: 100 %
Blood Pressure: 120/80 mmhg BMI: 46 percentiles
Weight: 168 pounds.
Height: 5.8”. Pain scale: 0/10.
Eye: normal PERRL, EOMI Ears, Nose, Mouth, and Throat: RT ear canal mild wax.
Ears, Nose, Mouth, and Throat: Normocephalic/atraumatic / extra ocular muscles intact / no discharge noted from nostrils / moist mucosa. Ear: The external ear was clear of cerumen
and the tympanic membrane intact, grey, and translucent and with normal
Head/Face: normal; Neck: normal.
CHEST: Normal appearance, symmetric. Normal Breath sound, equal bilaterally. No rales, no cough, no shortness of breath.
CVS: Regular rate and rhythm, no gallop, no murmur, no edema, peripheral pulses present, no cyanosis.
Gastrointestinal (Abdomen): Soft no tenderness, no organomegaly, no palpable mass.
Bowels sound presents, hydrocarbon noises present and normal in 10 minutes, no mane, diarrhea, no hernias. Defecates without difficulty.
Lymphatic: nontender cervical lymphadenopathy bilateral. No pain. EXTREMITIES: Symmetric, full ROM in all extremities.
SKIN: No other lesion in the body only on neck, good pigmentation, no hematoma, no bruising. No pain.
Neurological/Psychiatric: normal, Cranial nerves II-XII grossly intact, no focal deficits, no facial, no tongue deviation. No depression signs, good oriented person, time, and place.
Genitourinary: No pain in CVA, no lesions, no discharge, denies pain, burning, itching. Diagnosis:
ICD 10: J00. Common Cold; An acute, self-limited inflammation of the upper respiratory mucosa that may involve any or all the nose, throat, sinuses, and larynx. The condition is rarely characterized by a discrete set of specific symptoms, with the illness varying according to individual and causative pathogen. Occasionally there is spread to the lower respiratory tract.
Symptoms include sore throat, sneezing, blocked and/or runny nose, headache, cough, malaise, and low-grade fever. The condition is associated with more than 200 virus subtypes.
Differential Diagnosis:
ICD 10: J30.9; Allergic rhinitis; Rhinitis occurs in response to exposure to specific allergens. Chronic fluctuating course, according to allergen exposure and seasonal pattern. The presence of sore throat would make a common cold more likely. Other features of atopy suggestive of condition.
ICD 10: J32.9; Chronic sinusitis; Symptoms longer 6 weeks. Usually diagnosed with the aid of radiologic studies. Common clinical characteristics of chronic sinusitis include hyposmia or anosmia. More commonly characterized by chronic inflammation than a bacterial infection, especially in adults.
ICD 10: J03.00; Streptococcal tonsillitis, Use of the McIsaac score can help to discriminate; a score of 2 or 3 should lead to obtaining a throat swab. Tender anterior cervical glands, tonsillar swelling or exudates, absence of cough, temperature is greater than 100.4°F (>38°C), and age under 15 years.
Plan of Care:
Medication:
Naproxen: adults: 250 mg orally 1 tab, twice daily when required, maximum 1250 mg/day.
Oxymetazoline nasal: (0.05%): 1-2 drops/sprays in each nostril two to four times daily when required
Non pharmacology treatment:
Drinking plenty of fluids. Water, juice, clear broth, or warm lemon water are good choices. Avoid caffeine and alcohol, which can dehydrate you.
Eating chicken soup. Chicken soup and other warm fluids can be soothing and can loosen congestion.
Resting. If possible, stay home from work or school if you have a fever or a bad cough or are drowsy after taking medications. This will give you a chance to rest as well as reduce the chances that you'll infect others.
Adjusting your room's temperature and humidity. Keep your room warm, but not overheated. If the air is dry, a cool-mist humidifier or vaporizer can moisten the air and help ease congestion and coughing. Keep the humidifier clean to prevent the growth of bacteria and molds.
Soothing your throat. A saltwater gargle — 1/4 to 1/2 teaspoon salt dissolved in a 4-ounce to 8-ounce glass of warm water — can temporarily relieve a sore or scratchy throat.
Follow up: 1 week.
Referral: No.
References:
Monto AS. Occurrence of respiratory virus: time, place and person. Pediatr Infect Dis J.
2017 Jan;23(suppl 1): S58-64.
Kaiser L, Lew D, Hirschel B, et al. Effect of antibiotic treatment in a subset of common cold patients who have bacteria in nasopharyngeal secretions. Lancet. 2016 Jun 1;347 (9014): 1507-10.
Winther B, Brofeldt S, Christensen B, et al. Light and scanning electron microscopy of nasal biopsy material from patients with naturally acquired common colds. Acta Otolaryngol. 2014 Mar-Apr;97(3-4):309
Immunizations:
Vaccine 1st dose 2th dose 3th dose
Hep B 01/20/2006 03/01/2006 06/18/2006
DTaP 03/01/2006 06/18/2006 08/15/2006
Hib 03/01/2006 06/18/2006 08/15/2006
PCV 03/01/2006 06/18/2006 08/15/2006
IPV 03/01/2006 06/18/2006 08/15/2006
Rotavirus 03/01/2006 06/18/2006 08/15/2006
Flu 08/15/2006 01/12/2019 01/18/2020
Varicela 01/20/2010
MMR 01/10/2010
Meningoccoc al
Tdap 06/07/2018
DTaP 15m 06/23/2007
PCV 1year 01/20/2010
Soap note 3
Subjective:
CC: "My daughter is having headaches”.
HPI: A 16 year old female patient, of the white race of Hispanic origin, come with her mother, who reports that she has frequent headaches, which are intensified at night. She describes the pain in a non intense way, some days l hurts her head more than others, she feels it on her forehead, says that she does not run to any other place and that she is relieved when her mother gives her medicine (Acetaminophen). Denies fever, dyspnea, vomiting, nausea, other pain, and menstrual, digestive or other problems.
Family History (FH): Father Healthy, and Mother Obesity.
Social History (SH): No smoker, no alcohol, no drug, no coffee.
Allergy: No.
Medication: Acetaminophen 1 tab 325 mg q8hr.
OHx: Menarquia at 11 year, LPM 2 week ago, cycles every 28 days, duration 3 4 days. No sexual relations.
Hospitalization: no.
Surgery: No.
Develop Milestone:
Physical:
Have a big appetite
Need more sleep and may be sleepy in school if it starts early
Have the visual spatial coordination needed to help judge distance and speed and react quickly when learning to drive.
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Are more agile and coordinated, making it easier to do things like type on a keyboard or build complex projects.
Cognitive Milestones:
Start thinking more abstractly, comparing what is to what could be
Think about and come up with ways to deal with hypothetical situations
Begin to set their own goals for the future; take other opinions into account but make their own decisions.
Understand the consequences of actions, not just today, but also in far--reaching ways (For example, understanding that failing English isn’t just a bummer it can mean summer school, too).
Develop a strong sense of right and wrong and make decisions based on following their conscience.
Write with complexity about a variety of content areas (science, social studies, literature).
Use strategies to search for, use, and compare information from multiple sources.
Social and Emotional:
Start relating to family better; begin to see parents as real people.
Develop a better sense of who they are and what positive things they can contribute to friendships and other relationships.
Spend a lot of time with friends.
Are able to voice emotions (both negative and positive) and try to find solutions to conflicts.
Review of system:
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Constitutional: Denies weight gain or loss, normal gait, denies night sweats, fatigue, malaise, lethargy, fever or chills.
Head: reports headaches, denies lightheadedness or dizziness. Normoconfigured, 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.
Cardiovascular: denies chest pains, palpitations, tachycardia, or bradycardia.
Respiratory: denies cough, wheezing, hemoptysis, shortness of breath, denies changes in sputum.
Genitourinary: denies urgency, frequency, dysuria, hematuria, nocturia, obstructive symptoms, secretion, denies significant abnormal bleeding.
Gastrointestinal: Denies abdominal pain, nausea or vomiting, diarrhea or constipation, hematemesis, hematochezia, mane.
Musculoskeletal: denies musculoskeletal pain, inflammation of the joints, arthritis.
Hematologic/lymphatic: denies anemia, purpura, and petechiae, prolonged or excessive bleeding.
Skin: color pink, without lesions, no bruising, or hematomas.
Psychiatric: Denies history of psychiatric illness, denies anxiety, insomnia, tremors, behavior changes, denies having or suffering from phobias.
Neurological: refers headaches, describes as dull, No history of neurological diseases, well oriented in space and person time, No seizures, or involuntary movements, normal gait, normal language.
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Physical examination:
VS:
BP: 110/70 mm/Hg
HR: 80 ppm
RR: 16 rpm
Temp: 98.6 F
SO: 100 %.
Wt.: 47.5 Kg.
BMI: Pct.: 57.
Constitutional: normal Denies Poor Appetite, Denies Weakness, Denies Fever, Denies Weight
Loss, Denies Weight Gain, Denies Fatigue, in no acute distress, well-nourished.
Eye: normal PERRL, EOMI
Ears, Nose, Mouth, and Throat: Right ear canal mild wax. Ears, Nose, Mouth, and Throat: Normocephalic/atraumatic/extraocular muscles intact / no discharge noted from nostrils / moist mucosa Ear: The external ear was clear of cerumen and the tympanic membrane intact, grey, and translucent and with normal
Head/Face: normal; Neck: normal
Respiratory: Clear breath sounds bilaterally
Cardiovascular: normal RRR, S1 & S2, no MRG
Chest/Breasts: Symmetrical expansion, no palpable masses
Gastrointestinal (Abdomen): normal Non--Tender -- No CVT
Genitourinary: No pain in CVA, no lesions, no discharge
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Lymphatic: normal No Cervical, axillary, or femoral lymphadenopathy noted.
Musculoskeletal: normal FROM on bilateral lower and U/L Extremities, Strength 5/5
Skin: normal skin clean, dry, with no lesions, no rash, no equimosis, no petechias, no pruritus.
Extremities: normal Bilateral dorsal pedis (DP), pulse palpable, Right DP 2 +; left DP 2 +
Neurological/Psychiatric: normal, Cranial nerves II--XII grossly intact, no focal deficits, no facial, no tongue deviation. No depression signs, good oriented person, time and place.
Assessment:
ICD 10: R51: Headache, is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension--type headache, or cluster headache. Frequent headaches can affect relationships and employment. There is also an increased risk of depression in those with severe headaches. Headaches can occur as a result of many conditions. There are a number of different classification systems for headaches. The well--recognized is that of the International Headache Society. Causes of headaches may include dehydration, fatigue, sleep deprivation, stress, and the effects of medications, the effects of recreational drugs, viral infections, loud noises, common colds, head injury, rapid ingestion of a very cold food or beverage, and dental or sinus issues
Differential Diagnosis:
ICD 10: G44.209; Tension-type headache, unspecified, not intractable. Also known as tension-type headache (TTH) or stress headache, is the most common type of primary headache. The pain can radiate from the lower back of the head, the neck, eyes or other muscle groups in the body typically affecting both sides of the head. Tension-type headaches account for nearly 90% of all headaches.
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ICD 10: G44.019; Headache, Cluster. Is a neurological disorder characterized by recurrent severe headaches on one side of the head, typically around the eye. There is often accompanying eye watering, nasal congestion, or swelling around the eye on the affected side. These symptoms typically last 15 minutes to 3 hours. Attacks often occur in clusters which typically last for weeks or months and occasionally more than a year.
ICD 10: A87.0; Viral meningitis, also known as aseptic meningitis, is a type of meningitis due to a viral infection. It results in inflammation of the meninges (the membranes covering the brain and spinal cord). Symptoms commonly include headache, fever, sensitivity to light, and neck stiffness
Plan:
Imagine exam: none.
Medications:
Motrin 800 mg 1 tablet every 8 hours as needed for pain.
Lifestyle and home remedies
Rest, ice packs or a long, hot shower may be all you need to relieve a tension headache. A variety of strategies can help reduce the severity and frequency of chronic tension headaches without using medicine. Try some of the following:
Go hot or cold. Applying heat or ice —— whichever you prefer —— to sore muscles may ease a tension headache. For heat, use a heating pad set on low, a hot--water bottle, a warm compress, or a hot towel. A hot bath or shower also may help. For cold, wrap ice, an ice pack, or frozen vegetables in a cloth to protect your skin.
Perfect your posture. Good posture can help keep your muscles from tensing. When standing, hold your shoulders back and your head level. Pull in your abdomen and buttocks.
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When sitting, make sure your thighs are parallel to the ground and your head isn't slumped forward.
Follow up in the office in 2 weeks.
Referral: Ophthalmology evaluation.
References:
Consortium US Headache: Evidence-based guidelines in the primary care setting: Neuroimaging in patients with nonacute headache, 2017.
American Headache Society (September 2014). "Five Things Physicians and Patients Should Question". Choosing Wisely. American Headache Society. Archived from the original on 6 December 2013. Retrieved 10 December 2018., which cites
Lewis, D. W.; Dorbad, D. (2015). "The utility of neuroimaging in the evaluation of children with migraine or chronic daily headache who have normal neurological examinations". Headache. 40 (8): 629––632.
Immunizations: Vaccine 1st dose 2nd dose 3rd dose Others Hep B 03/20/2004 05/21/2004 07/18/2004 DTaP
05/25/2004
07/25/2004
09/27/2004
06/19/2005 Hib 05/25/2004 07/25/2004 09/27/2004 PCV
05/25/2004
07/25/2004
09/27/2004
03/19/2005 IPV 05/25/2004 07/25/2004 09/27/2004 03/20/2008 Rotavirus
05/25/2004
07/25/2004
09/27/2004
Flu 09/15/2004 03/19/2005 Varicella
03/19/2005
03/20/2008
MMR 03/19/2005 03/20/2008 Meningococcal
03/18/2015
03/22/2020
Tdap 03/20/2008 HPV
04/12/2016
Soap note 4
CC: Painful and swollen lymph nodes on the neck, armpit and elbow; sore throat; fever;
HPI:
Subjective.
H is a 10 year-old African American presented to the hospital today with the mother beside to answer questions. According to the mother H complains having a sore throat, swollen and painful lymph nodes. The patient had initially come to the hospital for the same condition some four days before which the mother explain that the conditions are worsening. H has been taking amoxicillin since the last doctor appointment that seems not to be working. The mother explains that the patient has been experiencing fever up to 101 for three past days. According to the patient he has experience one loop earlier but they have increased in number and are becoming large. The patient denies of having any injury but the mom explains that the boy had cold a week ago. The client has been utilizing cold medicines to help reduce pain and swelling on the impacted areas. The patient is unable to go to school the past two days because of the pains he rate to be 7/10. The client also says that he still have a sore throat and he is experiencing pain when swallowing. According to the mom, the patient is not taking his proper diet but he is managing to take fluid intakes. The client does not have any important medical history. The immunization have all been done incorporating the flu vaccine. Client is the only baby and there is no other child at home.
ROS
Constitutional symptoms-appropriate weight, overall healthy and appropriate height; active (Wallace & Franson, 2016).
Eyes- no glasses or eye contacts, no vision problems.
ENT- no hearing problems, co sore throat, no ear pain, visit the dentist for 6 months.
Cardiovascular- no palpitations or no chest pain
Respiratory- no SOB, no respiratory distress, no cough.
GI- a movement of the bowel once a day
GU- no penile pain, dysuria
Musculoskeletal- no muscle pain
Integumentary-no rash on the skin or itching
Neurologic- has no headache, no weakness
Psychiatric- no nightmares; patient is happy and respond to questions correctly when asked unswervingly
Endocrine- client is of fitting size and right weight for his age
“Hematologic/lymphatic- fatigue and swollen/tender lymph nodes in neck, armpit, and elbow
Allergic/immunologic- Per mom has seasonal allergies.”
Objective
Constitutional VS: Temp-99.3, HR-98, BP-102/69, Ht-52in, Wt-64.5lbs, BMI-16.6, Pt alert and oriented, patient respond to questions correctly when asked unswervingly. No signs of distress (Larimore & Jordan, 2015).
HEENT
Eyes - Extra ocular muscles intact, PERRLA.
Ear- No discharge, TM’s pearly grey bilaterally, EAC clear, hearing intact.
Nose- Bilateral turbinates’ red and swollen, septum midline.
Throat – Posterior pharyngeal erythema, white pus pockets noted on swollen tonsils
Cardiovascular – normal rhythm and rates; no murmurs
Respiratory - strong to auscultation all fields wheezes, no rhonchi.
Gastrointestinal - Soft, non-tender. No masses or organomegaly. No abdominal pulsations or bruits. Normal bowel sounds. Tanner stage 1.
Musculoskeletal – from all the extremities.
Integumentary - patient skin intact, no lesions noted. swollen lymph nodes palpated in neck, armpit, and elbow bilaterally with tenderness on palpation.
Neurologic - strength equal bilaterally, no weakness, respond to questions correctly when asked unswervingly
Psychiatric – good mood.
Hematologic – fatigue, no tint noted (Cameron & Turtle‐Song, 2015).
Assessment
Diagnostic Testing
Rapid Flu Swab – Negative
Rapid Strep Test- Negative
Additional Lab work not available at this time.
Patient should take pain relievers and visit the hospital twice a week for more lab test and check-up.
Plan
More lab test to diagnose what might be the cause of the illness.
References
Cameron, S., & Turtle‐Song, I. (2015). Learning to write case notes using the SOAP format. Journal of Counseling & Development, 80(3), 286-292.
Larimore, W. L., & Jordan, E. V. (2015). SOAP to SNOCAMP: Improving the medical record format. Journal of Family Practice, 41(4), 393-399.
Wallace, C. S., & Franson, K. L. (2016). Incorporation of ability-based outcome education into pharmacotherapeutics using an expanded SOAP format. American Journal of Pharmaceutical Education, 60(1), 87-92.