Previous Medical: Pre-diabetic (last HBA1C- 44mmol/L- 1 year ago)
Family Hx– mum- DM2, dad- gout, HTN
Medications: copper IUD Allergies: Penicillin- rash to face Job: RPN- Palliative Care
Presenting complaint: Sore throat and ear pain (both ears)
History of complaint:O- sore throat for 5 days. Ear pain starting 1 day ago
P- “swallowing makes my ears and throat sore” “ibuprofen helped a bit, but have to keep taking it”
Q- throat pain- sharp, ear pain- aching
R- throat pain- moves into my jaw and neck, ear pain- moves into my jaw and neck S- 6/10 before ibuprofen, 4/10 after ibuprofen
T- ear ache is “always there”, throat pain “comes and goes a little bit”
ON EXAMINATION (Objective)Temp- 37.9, RR 16, HR- 105, BP 140/82, 02- 98%
Airway patent, able to swallow. Respirations even and unlabored.
Skin warm and slightly diaphoretic. No rash. Lying in bed, appears tired.
EARS
Inspection: BILATERAL- External- nil redness, nil swelling. Yellow wax to canal- wet. Nil redness, swelling, or discharge to external canal.
TM (Tympanic Membrane) intact bilaterally. Flat, pearly grey in colour, Cone of light reflex R-5 o’clock, L-7 o’clock. Whisper test intact bilaterally. AC> BC
MOUTH/THROAT
Inspection: MMM, good dentation, tongue pink and even, bifid uvula present, cranial nerve X intact (have
patient say “ahh”- uvula elevates). Breath smells of smoke, tonsils 2+ bilaterally, redness, and exudate noted.
Palpation: superficial cervical and jugulodigastric lymph nodes swollen, approx. 1-2 cm, mobile, painful on palpation. R>L.
Bifid uvula- more common in Indigenous populations
- Write a SOAP note using the information provided above. For the “Assessment” include one priority NANDA diagnosis. Please use the NANDA Diagnosis Definitions and Classification 2021-2023 (Twelfth Edition) to support the development of your NANDA statement. Your “Plan” should address the priority NANDA diagnosis.
| Section | Information |
| Subjective | O- sore throat for 5 days. Ear pain starting 1 day ago
P- “swallowing makes my ears and throat sore” “ibuprofen helped a bit, but have to keep taking it” Q- throat pain- sharp, ear pain- aching R- throat pain- moves into my jaw and neck, ear pain- moves into my jaw and neck S- 6/10 before ibuprofen, 4/10 after ibuprofen T- ear ache is “always there”, throat pain “comes and goes a little bit”
|
| Objective | Temp- 37.9, RR 16, HR- 105, BP 140/82, 02- 98%
Airway patent, able to swallow. Respirations even and unlabored. Skin warm and slightly diaphoretic. No rash. Lying in bed, appears tired.
EARS
Inspection: BILATERAL- External- nil redness, nil swelling. Yellow wax to canal- wet. Nil redness, swelling, or discharge to external canal. TM (Tympanic Membrane) intact bilaterally. Flat, pearly grey in colour, Cone of light reflex R-5 o’clock, L-7 o’clock. Whisper test intact bilaterally. AC> BC MOUTH/THROAT Inspection: MMM, good dentation, tongue pink and even, bifid uvula present, cranial nerve X intact. Breath smells of smoke, tonsils 2+ bilaterally, redness, and exudate noted. Palpation: superficial cervical and jugulodigastric lymph nodes swollen, approx. 1-2 cm, mobile, painful on palpation. R>L.
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| Assessment | Risk for infection as evidenced by elevated temp and HR, as well as superficial and jugulodigastric lymph node swelling
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| Plan | Encourage fluid intake.
Blood work to assess infection. Consider Isolation Educate on use of antibiotics and the negative effects of smoking |