Mary

Interview responses: No reports of headache, fever, vision changes, ear pain, hearing

loss, or ringing in the ears. No reports of nasal congestion, or discharge; no report of sore throat, difficulty swallowing, wheezing, shortness of breath or cough. No reports of enlarged lymph nodes, chest pain, palpitation, or dizziness. Nothing seems to make the eye drainage better or worse. She has not tried any treatment at home. She did not go to work today, she did not want to infect her coworkers.

Physical Exam:

VS: height: 64 in, weight 149 pounds. BP 126/72, Temp 98.5, P 72, regular and RR 12.

General

Allert, oriented and cooperative. HEENT: head normocephalic. Hair thick with distribution throughout scalp. Eyes: Vision testing done using old glasses, using wears contacts. Snellen chart 20/50 right, 20/40 left and 20/30 both eyes.

No ptsosis. No lesions noted. Brows and lashes present. Left eye: no erythema or exudate noted. Sclera clear. Right eye: crusting noted on lashes with thick yellow mucous noted at medial canthus which returns rapidly after cleaning. Conjunctiva: red, PERRLA, EOMs intact. Corneal light reflex symmetrical bilaterally.

Fundi: red reflex present bilaterally, Discs flat with sharp margins. Vessels present in all quadrants without crossing defects. Retinal background has even color, no hemorrhages noted. Macula has even color.

Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. Cardiopulmonary: Heart S1 and s2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. Abdomen soft, nontender, bowel sounds auscultated in all four quadrants fields. No organomegaly noted.

Labs: adenovirus rapid screening test: negative

MaryKate

Interview responses: No reports of headache, fever, vision changes, ear pain, hearing loss, or ringing in the ears. Nasal congestion is improving, nasal discharge is clear. No report of sore throat, difficulty swallowing, wheezing, shortness of breath or cough. No reports of enlarged lymph nodes, chest pain, palpitation, or dizziness. Nothing seems to make the eye drainage better or worse. Tried Visine eye drops which burned and did not help with the drainage or redness.

Physical exam:

VS: height: 46 inches, weight 46 pounds; BP 82/50 T 99.0 P 92, regular RR 20.

General

Alert, oriented and answers questions appropriately/ HEENT: head normocephalic. Hair thick with distribution throughout scalp. Eyes: Vision testing by Snellen chart- right eye: 20/40, left 20/40, together 20/30.

No ptsosis. No lesions noted. Brows and lashes present. Tearing noted bilaterally, Conjunctiva red bilaterally, PERRLA, EOMs intact. Eyelids without erythema, no crusting noted on eyelashes.

Fundi: red reflex present bilaterally, Discs flat with sharp margins. Vessels present in all quadrants without crossing defects. Retinal background has even color, no hemorrhages noted. Macula has even color.

Tympanic membranes intact with bubbles noted. Pinna and tragus nontender. Nares with erythema, edematous with clear exudate noted. Oropharynx moist, no exudate. Teeth in good repair, no cavities noted. Tonsils ¼ bilaterally. Sinuses nontender to palpation. Neck supple. Mild anterior cervical lymphadenopathy noted bilaterally. Thyroid midline, small and firm without palpable masses. Cardiopulmonary: Heart S1 and s2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. Abdomen soft, nontender, bowel sounds auscultated in all four quadrants fields. No organomegaly noted.

Labs: adenovirus rapid screening test: positive

Discussion Part Two

Summarize the history and results of the physical exam for each patient in a SOAP note for each case study patient. – have this done!

Calculate the BMI for each patient. – have this done!

List the primary diagnosis with ICD10 code. Include your rationale for choosing the primary diagnosis. The diagnostic rationale in the assessment section should include your patients’ symptoms, exam findings and the interpretation of all presented lab findings. Include one evidence-based journal article or clinical guideline that supports your rationale for each patient. Develop a complete evidence-based treatment (EBP) plan for each patient that includes medications, any additional diagnostic tests, patient education, possible referrals, and a plan for follow up with you, the PCP. Each step of the plan must include an in-text citation to an approved reference as listed on the Reference Guidelines document. The guidelines for SOAP note documentation is located under Course Resources and can assist you in writing this post and your SOAP note.