SOAP note week 3 A 23-year-old Caucasian female presents to the clinic with a complaint of fever and sore throat

SOAP note week 3 A 23-year-old Caucasian female presents to the clinic with a complaint of fever and sore throat

SOAP note week 3 A 23-year-old Caucasian female presents to the clinic with a complaint of fever and sore throat

Please use the diagnosis below for the assignment. I have attached it for this assignment. Please use the headings on the document to complete each section and list information under the sections as labeled on the ATTACHMENT. Please be thorough and specific.

Primary Diagnosis:

• Pharyngitis group A, streptococcal

Differential Diagnosis:

• Influenza
• Pharyngitis, viral
• Covid-19
• Peritonsillar abscess

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Please list diagnoses with codes as noted in the attachments.

The guideline used to develop this primary diagnosis: (this will be specific to the diagnosis listed below that I have provided. Example: American Academy Of Allergy, Asthma, Immunology)

Medications include OTC, dosage, and education. Please list the medications you would prescribe with dosage and instructions.

Please be specific with the information requested below in this attachment section.

Social Determinants of Health to consider, Health Promotion and Pt risk factors. Please review the WHO website and search Social Determinants of Health for a review of what this is and what should be reviewed with the patient, Risk factors can be reviewed at the USPSTF website along with the recommended health screening exams based on age/sex. Include a list of recommendations for should this patient.

EPISODIC VISIT: HEENT FOCUSED NOTE

Focused Notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly learning resources. Focused Notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will work with a patient with a HEENT condition that you examined during the last three weeks and complete an Episodic/Focus Note Template Form where you will gather patient information and relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, past medical history (PMH), socioeconomic status, and cultural background. In this week’s Learning Resources, please refer to the Focused SOAP Note resources for guidance on writing Focused Notes.

Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using Turnitin.

Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

To prepare:

• Use the Episodic/Focus Note Template found in the Learning Resources for this week to complete this assignment.
• Select a patient that you examined during the last three weeks that suffered from any HEENT condition. With this patient in mind, address the following in a Focused Note:

Assignment:

• Subjective: What details did the patient provide regarding her personal and medical history?
• Objective: What observations did you make during the physical assessment?
• Assessment:What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
• Plan:What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
• Reflection notes:What would you do differently in a similar patient evaluation?

Note: Your Focused Note Assignment must be signed by Day 7 of Week 3.

BY DAY 7

Submit your Episodic/Focused Note Assignment.

(Note: You will submit two files, your Focused Note Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 3.)

SUBMISSION INFORMATION

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

1. To submit your completed assignment, save your Assignment as WK3Assgn2_LastName_Firstinitial
2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.

Rubric

PRAC_6531_Week3_Assignment2_Rubric

Management Plan

The Management Plan

The management plan is for the patient described. A 23-year-old Caucasian female presents to the clinic with a complaint of fever and sore throat for two days. She reports a mild headache that comes and goes. Reports that glands are really swollen and tender on both sides of her neck. Not shaking chills but chills. Pain to the throat when swallowing. Acetaminophen makes it better for a bit. Ice cream helps for a while too. The roommate said she had a really bad sore throat earlier and was checked at the clinic but was unaware of the diagnosis. Occasional engage in oral sex. Height: 67 inches, Weight: 120 lbs. BMI: 18.7. AAOX 4. Temp (101.5) oral. Pulse (94), BP (126/78), RR (14). PMH: Infectious mononucleosis at age 15.

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Primary Diagnosis: Pharyngitis Group A, Streptococcal (ICD 10 code: J02.0): Many bacteria and viruses are known to cause acute pharyngitis, and streptococcus pyogenes is known to cause the streptococcal pharyngitis group A. A patient with this condition may present with various symptoms such as fever, pain with swallowing, sore throat sudden-onset, cervical lymphadenopathy, palatal petechiae, tonsillar hypertrophy without or with exudates and pharyngeal and tonsillar erythema (Oliver et al.,2018). The patient presented with most of these symptoms, which makes the condition the primary diagnosis. In addition, the use of RADT also confirms the presence of the condition.

Guidelines Used In Developing Primary Diagnosis

Guidelines are important since they help practitioners in developing diagnoses of various conditions upon observing various symptoms in patients, coupled with what the patient reports. The guideline used for developing Pharyngitis Group A, Streptococcal as the primary diagnosis is the guideline endorsed by the American College of Physicians-American Society of Internal Medicine, The American Academy of Family Physicians, and the Centers for Disease Control(Mustafa et al.,2020). According to this guideline, a combination of clinical manifestations and  Rapid Antigen Detection Tests should be sufficient to diagnose this condition.

Differential Diagnoses

10. Influenza (ICD 10 code: J10.1): Influenza has been chosen as one of the differential diagnoses. A patient with this condition may present with various symptoms. The symptoms include eye pain, sore throat, runny nose, tiredness and weakness, shortness of breath, dry, persistent cough, headache, sweats and chills, aching muscles, and fever (Uehara et al.,2020). While the patient had some of the symptoms, she lacked a host of them, such as breath shortness, eye pain, aching muscles, and sweat, among others, making this condition less likely.
11. Pharyngitis, viral (ICD 10 Code, J 02.9): This is a condition where a patient presents with similar symptoms as in the case of step pharyngitis (Oliver et al.,2018). However, it can be ruled out using the RADT since the test will turn out to be negative. As such, the positive results make this diagnosis less likely.
12. Covid-19 (ICD 10 Code: U07.1): This is one of the most recent conditions. A person with this condition presents with symptoms such as headache, body or muscle aches, fatigue, breath shortness, cough, chills or fever, diarrhea, nausea or vomiting, runny nose, sore throat, and new loss of smell or taste (Alimohamadi et al.,2020). The patient also lacked many of these, making it less likely.
13. Peritonsillar abscess (ICD 10 Code: J36): This is a condition where there are tonsillitis complications, and the infection spreads behind the tonsils. The patient may present with various symptoms such as fever, neck or facial swelling, inability to swallow saliva, swallowing problems, pain with opening the mouth or difficulty opening the mouth, ear pain, severe throat pain, mostly on one side, fever, and chills (Zebolky et al.,2021).

Medications

The conditions can be managed using various medications. For the primary diagnosis (Pharyngitis Group A, Streptococcal), the patient should use penicillin orally, 250 mg, four times a day for ten days. In case of non-tolerance, the patient can use amoxicillin 800 mg for ten days. In the case of pharyngitis, viral, the patient should take acetaminophen (OTC) to help control fever (Mustafa et al.,2020). Another approach that can be used to relieve the symptoms includes gargling with warm salt water numerous times a day. In the case of influenza, the patient can use Rapivab, given as a 600 mg dose as an IV infusion. The patient is fully vaccinated for Covid-19, making this condition less likely. However, its management includes the use of 150 mg; 100 mg Dose Pack of paxlovid. The treatment of Peritonsillar abscess involves the use of Penicillin G (10 million units q 6 hours) with metronidazole (500 mg q 6 hours) (Zebolky et al., 2021). As part of the education plan, the patient needs to follow the prescribed medication regimen. In the case where the patient experiences adverse effects of the medication or worsening symptoms, then the patient should report or call the facility. The patient needs to take a lot of fluid and have enough rest. If the patient becomes free of the symptoms and tolerates the medication with no additional incidences, then the patient can come to the facility for a follow-up after six weeks

Problem Statement

This patient is presenting with symptoms making her uncomfortable, hence a need to trigger effective treatment and management. However, there is a need to carry out an appropriate diagnosis to help in choosing the right medication regimen. Patient education should be formulated based on patient characteristics to help in effective treatment and management.

Social Determinants of Health To Consider

            Social determinants of health dictate health outcomes; hence they should be considered for every patient (Donkin et al.,2018). One of the determinants of health for this patient is social support. The patient should have appropriate family support for moral and mental support to help her treatment and healing process. As part of the health promotion, the patient should desist from oral sex, which she has been engaging in some times. The patient should also avoid crowded places.  The most common risk factor for the condition is close contact with another person with the condition, while adults are at increased risk if they are parents of school-going children and are often in contact with children.

References

Alimohamadi, Y., Sepandi, M., Taghdir, M., & Hosamirudsari, H. (2020). Determine the most common clinical symptoms in COVID-19 patients: a systematic review and meta-analysis. Journal of Preventive Medicine and Hygiene, 61(3), E304. https://doi.org/10.15167%2F2421-4248%2Fjpmh2020.61.3.1530

Donkin, A., Goldblatt, P., Allen, J., Nathanson, V., & Marmot, M. (2018). Global action on the social determinants of health. BMJ global health, 3(Suppl 1), e000603.

Mustafa, Z., & Ghaffari, M. (2020). Diagnostic methods, clinical guidelines, and antibiotic treatment for group A streptococcal pharyngitis: a narrative review. Frontiers in Cellular and Infection Microbiology, 10, 563627. https://doi.org/10.3389%2Ffcimb.2020.563627

Oliver, J., Malliya Wadu, E., Pierse, N., Moreland, N. J., Williamson, D. A., & Baker, M. G. (2018). Group A Streptococcus pharyngitis and pharyngeal carriage: a meta-analysis. PLoS Neglected Tropical Diseases, 12(3), e0006335.https://doi.org/10.1371/journal.pntd.0006335

Uehara, T., Hayden, F. G., Kawaguchi, K., Omoto, S., Hurt, A. C., De Jong, M. D., … & Kida, H. (2020). Treatment-emergent influenza variant viruses with reduced baloxavir susceptibility: impact on clinical and virologic outcomes in uncomplicated influenza. The Journal of Infectious Diseases, 221(3), 346–355. https://doi.org/10.1093/infdis/jiz244

Zebolsky, A. L., Dewey, J., Swayze, E. J., Moffatt, S., & Sullivan, C. D. (2021). Empiric treatment for peritonsillar abscess: a single-center experience with medical therapy alone. American Journal of Otolaryngology, 42(4), 102954.https://doi.org/10.1016/j.amjoto.2021.102954