A fifteen-year-old female presents to your clinic complaining of shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately, she has felt this way continuously. She denies any other upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray but is otherwise on no other medications. She has had no surgeries.
Her mother has allergies and eczema, and her father has high blood pressure. She is the only child. She denies smoking and illegal drug use. On examination, she is in no acute distress and her vital signs are: T 98.6, BP 120/80, pulse 80, and respirations 20. Her head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs.
- What is the chief complaint?
- Based on the subjective and objective information provided what are your 3 top differential diagnosis listing the presumptive final diagnosis first?
- What treatment plan would you consider utilizing current evidence based practice guidelines?
Each week, you are required to enter your patient encounters into eMedley. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. You will also need to include a minimum of one complete SOAP note using this template . The SOAP note should be related to the content covered in this week, and the completed note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from eMedley.
- By the end of the week enter your patient encounters into eMedley and complete at least one SOAP note in the template provided.
- Name your SOAP note document SU_NSG6440_W2_SOAPLastName_FirstInitial.doc.
- Include the reference number from eMedley in your document.
- Submit your document to the Submissions Area by the due date assigned.
Use the following coupon code :