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Abby Fashakin

SOAP #1

Case Study Answer

SOAP #1 Abby N. Fashakin Thomas Jefferson University School of Nursing NU: 673. Comprehensive Assessment for Advanced Nursing Practice Sharon Rainer, Valerie Fulton, and Lori Prol

Abby Fashakin

SOAP #1

Case Study Answer

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History of Present Illness: JM is an 18 year old high school student who comes to the office complaining of an earache that has persisted for the last 3 days. His mom states JMs forehead felt hot at home, but she did not have a thermometer to check his temperature. He has a decreased appetite and a runny nose. The color of the nasal discharge was clear or sometime yellow. He has been sneezing occasionally. He denies any recent trauma to his ears. He denies sore throat, SOB, concurrent respiratory infection, and cough. PMH- denies PSH denies FMH denies JM states he does not smoke, drink alcohol, or abuse drugs. His mom states JMs immunizations are up to date.

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General Survey: JM is alert, awake, and oriented. He appeared healthy, but mildly ill. Vital Signs: temperature was 100.9 F; HR 78 bpm and regular; BP 104/66 mm Hg; RR 22 breaths/min. Skin: No rash present in any part of JMs body. HEENT: Head is atraumatic and normocephalic; PERRLA; constrict from 3mm to 2mm. External ear canal is patent, but with small amount of cerumen in both ears; Right tympanic membrane is red and bulging; left tympanic membrane is dull. The Nasal mucosa is pink, but his sinuses are both non-tender. JMs oral mucosa is pink without enlarges tonsils; his pharynx is without exudates.
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Abby Fashakin

SOAP #1

Case Study Answer

Neck: No enlarged thyroid gland; supple with spotty anterior cervical adenopathy. Thorax and Lungs: Thorax is symmetric with good expansion. Lungs resonant; breathe sounds vesicular Cardiovascular: PMI non-displaced and tapping. Carotid arties brisk, without bruits; Normal S1, S2; no S3, S4; no clicks, murmurs, or rubs. Labs Gram stain and culture if discharge is present in the canal. CBC

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Otitis Media (OM) [working diagnosis] is defined as inflammation in the middle ear, behind the tympanic membrane. The classic sign of OM is an erythematous, bulging tympanic membrane. There may be a meniscus level, indicating fluid behind the tympanic membrane. OM may or may not be accompanied with fever. Common bacterial causes: Streptococcus pneumoniae Moraxella catarrhalis - Haemophilus influenza - Group A streptococcus Common viral causes (most common cause): Respiratory syncytial virus Parainfluenza Rhinovirus - Influenza A - Adenovirus

Acute Sinusitis (AS) is a sudden onset of symptoms such as fever, malaise, nasal discharge, and cough, especially after a recent upper respiratory infection. Sinus is usually tender to palpation and the mucosa maybe erythematous and swollen. This can be caused by viral or bacterial infection. Common bacterial causes: Streptococcus pneumoniae Moraxella catarrhalis - Haemophilus influenzae - Anaerobes.
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Abby Fashakin

SOAP #1

Case Study Answer

JM had fever, nasal discharge, but no cough, and no sinus tenderness. AS is most likely not the diagnosis for JM. Allergic rhinitis (AR): is sudden onset of itchy eyes with clear discharge and clear nasal discharge with or without sinus itchy. Typically, there is no fever present. On physical examination, the tympanic membranes are shiny, or maybe slightly retracted; the nasal mucosa is pale and boggy. JM mucosa was pink, and his tympanic membranes red and bulging (R) and dull (L). AR is most likely not the diagnosis for JM.

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Treat Acute Otitis media with oral antibiotics and analgesics. Amoxicillin, analgesia with acetaminophen, ibuprofen, or topical anesthetic eardrops Surgical intervention requires myringotomy and tympanostomy tube placement. Necessary in cases involving recurrent infections or persistent middle ear effusion

Abby Fashakin

SOAP #1

Case Study Answer

References: Dains, J. E., Baumann, L. C., & Scheibel, P. (2012). Advanced health assessment and clinical diagnosis in primary care. (4th ed.). St. Louis, MO: Mosby.

Bickley, L. S., Szilagyi, P. G., & Bates, B. (2008). Bates' guide to physical examination and history taking. (10th ed.). New York, NY: Lippincott Williams & Wilkins. Maldonado, aniel ., and ynthia Blackwell Pub., 2005. Print. iga. O P for family medicine. Malden, Mass.