NSG6435 Week 1 Soap Note Meissner D

C ONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Note s 11202 3 Page 1 of 4 Student Name: Dina Meissner Course: NSG 6435 Patient Name: (Initials ONLY) CM Date: 11/30/23 Time: 1000 Ethnicity: White Age: 17 years old Sex : Female SUBJECTIVE (must complete this section) CC : Fever, sore throat, and rash HPI : The patient is experiencing fever, lethargy, new rashes, and a worsening sore throat. She adds that she had a temperature of 103 F four days ago, and it remained that way for 36 hours. The aching throat has gotten worse, and it's getting harder to drink and swallow solid food. As she tries to swallow or sip, the aching throat gets worse. She has been taking oral contraceptives every day, and yesterday she took Tylenol to help with her extremely painful throat. The aching throat gets worse when you drink and swallow. On the pain scale, she gives the pain a 6 out of 10. She exhibits bilateral swollen tonsils covered in gray exudate, as well as slight supraorbital edema. Medications : Junel Fe (Birth control) 1/28. Takes one daily at the same time of day for contraception Previous Medical History: Developmental History: Developed appropriately Allergies: NKDA Medication Intolerances: None Chronic Illnesses/Major traumas: None Immunizations: Up to date Hospitalizations/Surgeries: None Health Promotion/Health Maintenance: Exercises 3 times a week Nutrition/Diet: Exercise/Regimen: runs track 3 times a week Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: Denies Safety Measures: Screening exams: F AMILY HISTORY (must complete this section) M: Livin g, h/o HTN MGM : Livin g with brea st canc er MGF F : PGM: PGF Social History: Patient is a senior in high school. She reports living at home with her parents and doing well in school. She reports having a relationship with her boyfriend and using condoms and birth control . REVIEW OF SYSTEMS (must complete this section) General : acknowledges fever and malaise. Reduces fatigue, sluggishness, and night sweats Cardiovascular : denies having palpitations and chest pain. Skin : Reports rash on torso Respiratory: Denies any shortness or breath or difficulty in breathing Eyes : Denies change in vision or drainage from eye Gastrointestinal: denies experiencing

C ONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Note s 11202 3 Page 2 of 4 hematemesis, diarrhea, constipation, nausea, vomiting, or abdominal discomfort . Ears : Denies earache Genitourinary/Gynecological: denies experiencing pain, bleeding, discharges, obstructive symptoms , urge, dysuria, or hematuria on a regular basis. Nose/Mouth/Throat. denies congestion, odynophagia, sinus discomfort, running nose, and epistaxis. Recognizes sore throat Musculoskeletal: denies any swelling or joint pain Breast: denies having lumps, discharges, or breast pain. Neurological : denies experiencing seizures, syncope, disorientation, headaches, neck discomfort, or weakness. Heme/Lymph/Endo: denies polyphagia, polyuria, polydipsia, and weight loss denies having anemia, petechiae, purpura, and heavy bleeding. Psychiatric : Denies any confusion OBJECTIVE (Document PERTINENT systems only, Minimum 3) Weight : 125lb Height : 5ft4in BMI : 21 .5 BP: 110/60 Temp : 102.2 Pulse: 107 Resp : 21 SPO2 %: 100% General Appearance: Pt appears healthy looking but febrile Skin : Generalized maculopapular rash over her body HEENT: Gray exudate covering both large tonsils. Palate and uvula have little petechiae. Both posterior cervical lymphadenopathy on both sides Cardiovascular: Regular rate and rhythm Respiratory : No adventincious lung sounds. No dyspnea noted on exam . Gastrointestinal: Breast : Genitourinary : Musculoskeletal: Neurological: Psychiatric : Diagnostic Studies: CBC – WBC 17 Mono - positive Special Tests: N/A DIAGNOSIS (Minimum required differential and presumptive dx's, can do more) Differential Diagnoses  Diagnosis, (ICD 10 code and reference): Infectious mononucleosis B27.90 "Mono," or infectious mononucleosis, is a communicable illness. Infectious mononucleosis is most commonly caused by the Epstein-Barr virus (EBV), although other viruses can also cause this illness. Teenagers and young adults—especially college students—frequently experience it. When teens and young adults contract EBV, at least one in four of them will experience infectious mononucleosis (Naughton et al., 2021).  Diagnosis, (ICD 10 code and reference): Cytomegaloviral disease B25.9 A particular kind of herpes virus, known as cytomegalovirus (CMV), causes illness by using your cells to replicate itself. Most infected individuals have few or no symptoms, however many will get sick at some point in their lives. Serious consequences can arise from CMV in individuals with weakened immune systems (Fulkerson et al., 2021).  Diagnosis, (ICD 10 code and reference): Lyme Diagnosis  Presumptive diagnosis (ICD 10 code and reference): Infectious mononucleosis B27.90

C ONPH NSG6435 Subjective, Objective, Assessment, Plan 11202 3 Page 4 of 4 384. https://doi.org/10.21775/cimb.042.333