Chief Complaint (CC): “I have been experiencing shortness of breath and fatigue in the last two weeks.”
History of Present Illness (HPI): Patient complains of shortness of breath, and general fatigue. Patient has been experiencing swelling of the feet and has been having difficulty in completing tasks that she would normally.
Past Medical History (PMH): measles at age 3, mumps at age 4
Past Surgical History (PSH): None
Family history;
Father died at age 65 y/o due to CAD.
Mother 70 y/o, alive diagnosed with hypertension
Brother (35) alive and healthy
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Personal and Social History:
She is born and raised in this community. She is a college graduate with a diploma in business management. She works as an assistant in one of healthcare facilities within the community. She lives with her daughter. She interacts with the community members. Pt denies smoking, but takes a lot of salt. The pt takes two cups of caffeine. Pt states that she is physically inactive.
Review of Systems:
HEENT: EOMI, PERRL,
CV: RRR, S3 present, m/r/g absent
RESP: breathing symmetrical, SOB, CTAB x mild crackles
Healthy dietary is recommended to boost the immune system
Maintain hygiene to protect themselves from communicable diseases.
Reflections
Congestive heart failure (CHF) is the leading cause for hospitalization in this community. There is no cure of the disease, but can effectively be managed through therapeutic and non-pharmacological measures (Esposito, Bagchi, and Verdier, 2009). My preceptor and I were on the same page in during care delivery and treatment of this pt. From the comprehensive assessment, I learnt that the patient was non-compliant to medication.I was assigned to research on the strategic ways that would be used to educate the patient and to ensure that she adhered to the recommended medication (Bickley, 2013
Esposito, D., Bagchi, A., Verdier, J.M. (2009). Medicaid beneficiaries with congestive heart failure: Association of medication adherence with healthcare use and costs. The American journal of managed care 15(7); 437-445
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Acute Tonsilitis
Subjective Data:
Name: J.W. Date: 2/27/2016 Time: Case ID #: 8008-20164545-015 Age: 35 years old Sex: Female SUBJECTIVE
CC: Patient feels sick, with multiple symptoms including skin rash, fever, headache, pain in swallowing, sore throat, abdominal pain, nausea and vomiting.
HPI:
The patient is a 35 year old female who presented to the clinic on Saturday, complaining that she has been feeling sharp pain in her abdomen and severe headache. She also notes that she has been experiencing the following symptoms sore throat, pain when swallowing food and nausea plus vomiting.
Patient is accompanied by her 15 year old daughter and 42 year old husband, who bring her to the clinic. J.W. further notes that she has fever and the symptoms began about three days ago, with the sore throat setting in suddenly. This is the first incident that the patient reports to the clinic. The patient notes that she took acetaminophen to relieve the fever and headache, but she decided to consult further treatment once she developed a skin rash.
Medications Currently in Use: Acetaminophen
Past Medical History
Allergies: Allergic to sulfa containing compounds. Had complications after using sulfonamides
Medication Intolerances: Intolerant to sulfonamides and generally sulfa containing drugs
Chronic Illnesses/Major traumas: no major illness/traumas Hospitalizations/Surgeries: No surgical history recorded; hospitalized once due to pneumonia infection Family History: No family history recorded on major illnesses; patient’s mum in good health
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Social History
Patient is a casual laborer living with her daughter and husband, plus her 54 year old mum. She takes her lunch from a local cafeteria, but cooks breakfast and supper at her home when she arrives from job in the evening. Her mum helps her cook food, but rarely when she is not present, ill or too tired to cook.
The patient states that she started to suspect food from the cafeteria after a change in management about a month ago. However, she continued to take lunch at the same place, but notes quality had significantly dropped. Also, she had heard a complaint from a regular customer, John, that the food was making him bloat his stomach two weeks ago though the condition disappeared without him attending to hospital.
Review of Systems General
Positive for fever: No Cardiovascular symptoms. This time she was using acetaminophen Denies chest pain, palpitations, PND, orthopnea, edema
Has a history of hx pneumonia but negative at the time of admission
Only reports for pain in her abdomen
Skin Denies bruising, delayed healing, bleeding or skin discolorations. Has no lesion changes or moles but presents with a skin rash
Respiratory Patient denies cough, breathing regular and symmetrical.
Eyes Denies eye discharge, no blurred vision, sees clearly without any aid
Gastrointestinal Reports pain in the abdomen
Ears Denies pain in ears has no ear discharge, hearing loss, or ringing in ears.
Genitourinary
Denies concerns
Nose/Mouth/Throat Positive for sore throat
Musculoskeletal Denies concerns
Breast Negative history
Neurological Denies syncope, seizures, transient paralysis, weakness, paresthesia, black out spells
Psychological: Denies depression, suicidal thoughts, irritability, sleep disturbances, and anxiety
Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance Psychiatric Denies concerns
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Objective Data
Physical exam is done in the clinic, after which the patient is sent for a lab test out of the clinic. Case is suspected to be upper respiratory bacterial infection particularly streptococcal infection. The following data is recorded from the physical exam;
General Appearance Constitutional marked as unremarkable: well developed: well nourished; no acute distress. Vital signs also noted as within acceptable limits. Patient dehydrated. General impression: A&Ox3, nicely dressed, appear appropriate, restless but cooperative, complains of chronic pain in the abdomen and headache
Skin Skin is black, warm, dry, clean and intact. No lesions noted upon examination. Scarlatiniform rashes noted HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed.
Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection.
Nose: Nasal mucosa pink; normal turbinates. No septal deviation.
Neck: Supple. Full ROM.
Pharynx redness or exudates over the tonsils noted plus erythema. Beefy red swollen uvula: Anterior cervical Adenitis and Soft Palate Petechiae noted. Teeth and gums are however unremarkable
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Cardiovascular S1, S2 with regular rate and rhythm. Heart location and apex is normal. No murmurs; no rubs, gallops, or click; femoral pulses normal.
Respiratory Respiratory unremarkable; respiratory rate and pattern normal; lungs clear to auscultation bilaterally.
Gastrointestinal Abdomen is soft, non tender and non-distended. No palpable masses. Liver and spleen normal; no hernias; normal bowel sounds, no bloating, only pain in the abdomen noted
Breast Chest/breast unremarkable, no masses palpitated, no redness
Genitourinary Bladder is non-distended, no UTI present
Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room.
Neurological Speech is clear, Good tone plus Posture erect. Balance is stable; gait normal.
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Assessment
Diagnostics & Lab Tests
Throat smear culture and blood specimen used
Incubation of the culture done for 48 hours before test
The suspected case is streptococcal infection by S. pyogenes or GAS
Positive rapid streptococcal test
Positive results for Antistreptolysin O test
Special Tests
Latex agglutination immunoassay test positive
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Assessment Findings and Plan
Diagnosis:
Patient confirmed to be having Group A Beta hemolytic Streptococcal infection, related acute pharyngitis and acute tonsilitis
Medication:
Penicillin V 500 mg tid for daily 10 days or Amoxicillin 500 mg tid for 10 days
Continue with Acetaminophen till fever completely subsidizes
Amoxicillin is a substitute in the event the patient reports to be allergic to Penicillin
Drugs to be taken orally and in full dosage given by a pharmacist
There are no generic substitutes available
Education
Advice patient to take the following measures:
Use OTC acetaminophen only for fever if relapsing occurs
Wash hands well with soap and water after using bathroom or before eating
Rinse food well and cook properly before eating
Drink water that has been purified or filtered only
Not to smoke or drink alcohol before medication is over and tests negative for GAS
If possible carry packed lunch or change the place she takes lunch from
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Further Notes:
The likely cause of the GAS infection is food from the cafeteria that the patient takes lunch. This, she should refrain from consuming food from the place to avoid a recurrence of the infection. High hygiene standards must be maintained to ensure zero infections to the members of her household, who include her daughter, husband and mum. Also, if convenient to her report the matter concerning the low quality food being sold at the cafeteria to public health offices, for further investigation.
Follow up Schedule
The patient is advised to report to the clinic after a week, for assessment of dosage coverage and progression of the illness. This is to ensure she completes the dosages of all medications in order to eliminate all GAS in her system and avoid development of antibiotic resistance to the Penicillin V given, which results from an incomplete dosage. In this regard, the patient should be advised strongly on the importance of completing her medications, with two follow up meetings being scheduled after a week each.
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Evaluation and Revisions:
The subjective and objective data was collected accordingly but the diagnostics did not cover all possible infections. Since the above are confirmatory of GAS infection, as the cause of the acute pharyngitis and acute tonsillitis, there was deemed no need to conduct tests for other upper respiratory bacteria on the cultures.
This is not only to eliminate the chances of it being a multiple infection case, but also to dictate the medicine given. This revision is necessary alongside a confirmation from the patient concerning her status in connection penicillin allergy, which should dictate the type of antibiotic given. This should be handled accordingly by the pharmacist addressing the prescription.
Metronidazole, Trimethoprim, Tetracyclines and flouroquinolones should not be used for the following reasons. Metronidazole is not effective against S. pyogenes while the patient is allergic to sulfa compounds hence Trimethoprim is contraindicated.
On the other hand, Tetracyclines pose a very high susceptibility to resistance by the bacterial species, that is GAS. Finally, Flouroquinolones are very expensive and have an unnecessary broad spectrum of activity, hence a more specific antibiotic is necessary including the above named plus Azithromycin, Clarithromycin, Clindamycin and various Cephalosporins.
Camara, M., Dieng, A., & Boye, C. S. B. (2013). Antibiotic susceptibility of streptococcus pyogenes isolated from respiratory tract infections in dakar, senegal. Microbiology insights, 6, 71.
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SOAP Note for a Patient with; Ectopic Pregnancy
Subjective
A 30-year-old female, gravid 1, para1+0.The patient complained of abdominal pain in the right adnexal area which was generalized. She complained of dizziness, light headedness, and syncope. She experienced abnormal uterine bleeding for three days. She had not undergone and gynecological operation and had been on folic and iron supplements. Her menarche was at the age of 14years. Her menses were regular and used to last for 5days and occurred every 28days.The patient had used hormonal implant for three years and had been removed three months ago. She had not received her menses for two months. She was sexually active and had post-coital bleeding. She used to take alcohol on a regular basis.
Objective
The patient was sick looking and was groaning in pain.On palpation, there was generalised abdominal tenderness, and unilateral adnexal mass was present on the right hypochondria. Her vital signs were; Temperature -36.7degrees Celsius, blood pressure-98/56 mm/Hg, pulse-50beats/min. On bimanual examination, there was cervical motion tenderness. Her Serum HCG levels were 4500 IU/l; a trans-vaginal Ultrasound revealed a tubal mass in absence of intrauterine gestational sac.
Assessment
Ectopic pregnancy which leads to acute abdominal pain and bleeding (Marion & Meeks, 2012).
Ovarian torsion resulting in localized lower abdominal pain radiating to the back or thigh and nausea and vomiting
A Urinary tract infection leading to lower abdominal pain and dysuria and increased micturition
Appendicitis presenting with guarding abdominal pain and nausea and vomiting. Diagnosis of ectopic pregnancy was made due to the acute abdominal pain, associated bleeding, and increased βhCG levels
Plan
The overall goal of management was to preserve the life of the mother, and this was managed through termination of pregnancy and reconstruction of the implantation site. The patient was given a bed rest ensure that she had reduced activity (Marion & Meeks, 2012). The patient was cannulated and started on intravenous fluids to restore the fluid volume deficit. Blood samples for the laboratory were obtained. Relaxation techniques were used to relieve pain.
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Medical management
The patient was put on intramuscular methotrexate. Methotrexate is a folic acid antagonist which deters cell division. The products of conception degenerates and detaches from the uterus leading to death (Epee-Bekima & Overton, 2013). Viability of the cytotrobhoblast is prevented together with β-hCG secretion (Wright, Busbridge & Gard, 2013).
Surgical management
Laparoscopic salpingectomy was considered to be the primary treatment of the ectopic pregnancy. Salpingectomy was conducted so as to repair the ruptured fallopian tube (Marion & Meeks, 2012).
Alternative management
Expectant management, the ectopic pregnancy could be waited to resolve on its own. However, this would be followed by β-hCG measurement and trans-vaginal ultrasound to confirm whether the disorder has resolved (Epee-Bekima & Overton, 2013).
Follow-up
The patient was advised to visit the clinic after 3-4 weeks for b-hCG measurement and ultrasonography. The patient was also advised on early pregnancy clinic visits.
Reflection notes
Patient involvement: I would carefully advise my patient of the advantage associated with any of the treatment approaches and ensure she fully participates in the selection of the mode of therapy. The use of laparoscopy could be used so as to come up with the diagnosis so as to minimize use of Surgery is the primary form of treatment. In addition to that, a less surgical procedure such as laparoscopic approach would have been used since it is associated with minimal intra-operative blood loss and hospital stay.
Marion, L. L., & Meeks, G. R. (2012). Ectopic pregnancy: history, incidence, epidemiology, and risk factors. Clinical obstetrics and gynecology, 55(2), 376-386.
Mergenthal, M. C., Senapati, S., Zee, J., Allen-Taylor, L., Whittaker, P. G., Takacs, P., … & Barnhart, K. T. (2016). Medical management of ectopic pregnancy with single-dose and 2-dose methotrexate protocols human chorionic gonadotropin trends and patient outcomes. American Journal of Obstetrics and Gynecology.
Practice Committee of the American Society for Reproductive Medicine. (2013). Medical treatment of ectopic pregnancy: a committee opinion. Fertility and Sterility, 100(3), 638-644.
Wright, S. D., Busbridge, R. C., & Gard, G. B. (2013). A conservative and fertility-preserving treatment for interstitial ectopic pregnancy. Australian and New Zealand Journal of Obstetrics and Gynaecology, 53(2), 211-213.
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