Exam (elaborations)
(SOAP NOTE) NR511 MARY 40 YO FEMALE CAUCASIAN (CC Sore Throat)
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- Chamberlain College Nursing
(SOAP NOTE) NR511 MARY 40 YO FEMALE CAUCASIAN (CC Sore Throat)
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Sore ThroatMarried, drinks alcohol socially, denies tobacco or illicit drug use.
difficulty swallowing, denies cough and hoarseness.
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, HEENT: Head: Normocephalic. Hair thick and distribution throughout scalp. Eyes: without exudate, sclera
clear. Contact lenses noted. Ears: Tympanic membranes gray and intact with cone of light noted. Pinna and
tragus non-tender. Nose: Nares patent without exudate. Throat: Oropharynx moist with erythema with
white exudate noted. Tonsils 3/4 bilaterally. Teeth in good repair, no cavities noted. Neck supple.
Thyroid midline, small and firm without palpable masses.
Cardiovascular: S1 S2 noted, no murmurs, palpitations, chest pain or discomfort noted. Tachycardia.
Respiratory: Respirations even and unlabored, no distress noted. Lung sounds CTA all anterior and
posterior lung fields bilaterally. No SOB, wheezing, or cough observed.
Gastrointestinal: Abdomen soft, non-tender, bowel sounds present all four quadrants. No organomegaly
noted.
Lymphatics: Anterior cervical lymph tender to palpation. No lymphadenopathy.
Diagnostic results: Rapid strep test positive.
A:
Streptococcal Pharyngitis (ICD-10 J02.0): Infectious inflammation of the pharynx and the pharyngeal
tonsils, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Pharyngitis and tonsillitis usually occur at the
same time and these two diseases are contagious. This is caused by the Group A beta-hemolytic streptococcal
infection, which is caused by group A Streptococcus. This can cause scarlet fever or autoimmune rheumatic
fever it not treated with antibiotics, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). People diagnosed
with this illness must have 2-3 of the following symptoms and if they do the Rapid strep test is performed
and antibiotic therapy started symptoms include fever greater than 100.5, tonsillar exudate, tender anterior
cervical lymphadenopathy, and no cough (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Mary
presents with all these symptoms.
P:
Medications:
Rx: Amoxicillin
Amoxicillin 500 mg capsules
Sig: 1 cap PO BID Disp #20 (twenty), No refills (Epocrates, 2017).
Rx: Acetaminophen
Acetaminophen 325 mg 2 tabs PO every 4-6 hours as needed for pain or fever, (Dunphy, Winland-Brown,
Porter, & Thomas, 2015).
Nonprescription throat lozenges as needed for pain, (Dunphy, Winland-Brown, Porter, & Thomas, 2015).
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