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NR 509 Week 3 i-Human Virtual Patient Encounter - Amanda Wheaton; 23 years old

Chamberlain University Nursing NR 509 Advanced Physical Assessment Laci Peterson 17 pages
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30. Nausea or vomiting? No 31. Muscle pain or cramping? No 32. Gland tender, painful or hard? Tender, painful to touch 33. Any rash? No HPI Sx = sore Sx = Sx = swollen and Sx = fever Sx =difficulty Sx throat headache tender neck gland with chills swallowing = Onset two days ago two days two days ago two days ago Two days ago ago Location throat head neck Duration 2 days come and n/a Come and go persistent go Characteristics " like ice mild very tender.painful temp 101.8, " β€œhurts” pick" headache to touch felt horrible" Aggravating none none none With sore throat tyenol and ice Tylenol but Relieving cream helps a tylenol none fever comes none little back Timing / tylenol tylenol tylenol tylenol Treatments Severity 11/10, " hurts mild painful to touch, like hell" tender History 1. Reason for encounter- The patient presents with a sore throat 2. History of present illness (HPI) Amanda Wheaton, a 23-year-old female law student with a history of infectious mononucleosis at age 15, presents with a severe sore throat for two days. She describes the pain as β€œsharp like an ice pick” and rates it β€œ11/10” in severity. She also reports intermittent fever with chills (temperature 101.8 F last night), a mild headache, and swollen, tender neck glands that are painful to touch, which started two days ago. Acetaminophen has provided only temporary relief, and she notes that ice cream offers slight relief for her sore throat. She denies any specific aggravating factors. She reports sick contact with her roommate, who had a sore throat earlier in the week. 3. Review of systems β€’ General- The patient reports feeling healthy before symptoms onset. The patient reports fever (temperature 101.8F last night) and chills. Denies any weight loss. β€’ HEENT/neck Name: Amanda Wheaton Age: 23 Sex: F Height: 67 Weight: 120 lb BMI: 18.8 Cognitive status: A and O x 4 Temp : 38.6 C ( 101.5F) oral Pulse: 94 bpm, rhythm, regular, strength: normal BP: left 126/80; right : 126/78--- normotensive, pulse pressure-normal Respiration- 14 bpm, rhythm-regular, effort- unlabored SpO2- 98% β€’ General- well-groomed, calm, alert & oriented x 4, not in any distress β€’ HEENT/neck 1. Head- normocephalic, atraumatic 2. Eyes- PERRLA, no erythema, drainage or swelling. 3. Ears- external ears without deformities, lesions, masses, or erythema. Canals without edema or erythema. Tympanic membranes are non-bulging, translucent, and pearly gray with an intact cone of light bilaterally. No perforations, erythema, or exudates bilaterally. 4. Nose- no discharge or polyps. Nasal mucosa pink and moist. 5. Throat- enlarged tonsils, right slightly larger than left, with prominent exudates bilaterally. Posterior pharynx erythema. No oral ulcers or vesicles. Uvula midline. 6. Neck- thyroid mobile without masses, tenderness, nodules, or enlargement. Bilateral tender cervical lymphadenopathy, nodes approximately 1.5 cm in size, rubbery and mobile β€’ Cardiovascular- regular rate and rhythm without murmurs. No thrills or bruits. β€’ Infectious mononucleosis at age 15-----missed β€’ Lack of cough-----missed β€’ Lack of flu vaccine β€’ Additional

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