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You are seeing a 34-year-old multi-race female who is a school counselor. • She reports a 3-day history of a sore throat, rhinorrhea, nasal stuffiness and postnasal drip. • She states she thinks she may be running a low-grade fever but reports she has not actually taken her temperature. • She reports feeling tired. • She has a history of migraine headaches for which she utilizes ibuprofen as needed. She has a script for Maxalt if needed however reports she hasn’t used that in several years. • She is on hormonal contraceptive management. BP 112/66, P 68, Resp 18, Temp 98.7, SpO2 99% on RA • On your exam you note clear nasal discharge, tympanic membranes are pearly gray, posterior pharynx is erythematous, no tonsillar enlargement noted. • Breath sounds are clear bilateral. Please develop a discussion that responds to each of the following prompts. Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan). Structure your ‘P’ in the following format: Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional – any other therapies in lieu of pharmacologic intervention] Educational: health information clients need in order to address their presenting problem(s); health information in support of any of the ‘therapeutics’ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit Consultation/Collaboration: if appropriate – collaborative ‘Advanced Care Planning’ with the patient/patient’s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making
SCIENCE
HEALTH SCIENCE
NURSING
NU 609
