Subjective Data
Identifying Information
Name: John Jone
DOB: August 29, 2000
Gender: Male
Race: Caucasian
Usual source of medical care: pediatrician’s office, attending practice for the first time
Patient provided information on his own, aware and oriented, reliable as a historian.
Chief Complaint
“I have a sore throat for three days now, the ache is stronger closer to the evening, and it hurts when I swallow.”
History of Present Illness
17-year-old Caucasian male with no major health concerns and/or history of family illness.
No reported hospitalizations, surgeries, or major illnesses/health conditions for one year prior to the admission.
Illness: A sore throat. Onset – three days before the admission. Frequency – constant. Location: throat, pulsating headache in the whole head, swollen glands. Characteristics – persistent, dull, strengthened closer to the end of the day. Aggravating factors – pain is stronger during swallowing. Relieving factors – medications (ibuprofen). Timing – three days with no sign of relief. Progression since the onset – addition of abdominal pain and pounding headache. Patient’s perception – pain reported as severe (8/10), disruption of daily routines (has difficulty eating and drinking), increased tiredness, disruption of academic activity (missed three days of school). Precipitating factors not identified.
Review of Systems
Head: Reported pounding headache across the whole head.
Ears, nose, throat, and mouth: Swollen glands. No nasal congestion. No sinus pressure. No ringing in ears. No ear pain. No jaw pain. No tooth pain.
Eyes: No reported vision problems.
Chest and lungs: No cough, no shortness of breath, no pain in the chest.
Gastrointestinal and endocrine system: dull pain throughout the course of illness. Pain in the tip of the abdomen. No reported change in bowel movement, one BM per day. Normal bowel movement this morning (LBM).
Musculoskeletal system: body ache throughout the course of illness (relieved by Motrin).
Past medical history – no reported major illnesses.
Past hospital, surgical, and injury history – N/A
Allergies – N/A
Medications: Ibuprofen, Motrin, cough drops (unidentified, stopped using due to ineffectiveness). No flu immunizations.
Pertinent social history and habits – lives with parents (both employed) and two sisters. Feels safe at home. Good academic performance. No mood disorders, no suicidal thoughts. Has a girlfriend. Not sexually active.
Family History – no illness observed in the family. No record of similar symptoms in the past.
Objective Data
Physical Exam
Vital signs: blood pressure 125/85. Heart rate 65 bpm, regular. Respiratory rate 15 per minute. Temperature 102 F. Patient not in distress, is not under the influence of drugs or alcohol, articulates clearly. Alert, aware and oriented. Poor state of well-being due to severe pain and disrupted routines and habits.
Pertinent positive findings – persistent pounding headache, abdominal pain, soreness in the back of the throat, high temperature, tiredness, painful sensation during swallowing, swollen glands. Overall pain in the musculoskeletal system.
Pertinent negative findings – no cough, no nasal congestion, no ear pain, no ringing in the ears, no sinus pressure. Abdominal pain not accompanied by disrupted bowel movement cycle. No previous personal or family history of similar illnesses in the past year.
Assessment
Primary diagnosis of illness: Flu (ICD-10-CM Diagnosis Code J11.1). The common symptoms of the illness include high body temperature (over 100 F), headaches, body ache, sore throat, weakness and tiredness, and, on some occasions, abdominal pain (Healthline, n.d.a). The symptoms can become stronger closer to the end of the day. Some types of influenza are not associated with lower respiratory symptoms such as cough (Healthline, n.d.a). The absence of flu immunizations increases the likelihood of developing the disease.
Differential Diagnoses
Strep throat (ICD-10-CM Diagnosis Code J02.0). A bacterial infection of the higher respiratory systems that results in the inflammation and discomfort in the throat. Many of the positive findings are consistent with the condition, including a sore throat, pain during swallowing, fever, high temperature (above 100 F), and pounding headache (Healthline, n.d.b). However, neither abdominal pain nor body pain is characteristic of the condition. In addition, strep throat is unlikely to develop without cough.
Tonsillitis (ICD-10-CM Diagnosis Code J03.90). The condition resulting from the inflammation of the tonsils caused by overexposure to the viruses or bacteria. Commonly occurs as a result of a bacterial infection but can be caused by a viral disease such as influenza. Pertinent positive findings consistent with the diagnosis include swollen glands, headache, throat pain during swallowing, fever, and abdominal pain (WebMD, n.d.). However, the pertinent negative findings of ear pain and the characteristic white coating of the tonsils must be taken into account.
Toxic Shock Syndrome (ICD-10-CM Diagnosis Code A48.3). A severe health condition caused by the bacterial toxins in the bloodstream. The condition is associated with symptoms such as fever, headache, abdominal pain, tiredness, redness and pain in the throat, and muscle aches (Mayo Clinic, n.d.). However, it is inconsistent with several negative findings, namely the absence of vomiting, nausea, disruption of bowel movement, diarrhea, confusion, and redness of the eyes. In addition, the condition is relatively rare and is uncommon in association with flu.
Health Promotion Diagnosis
The lack of awareness of the importance of seasonal vaccinations in the patient’s family. The fact that John’s mother is against the flu shots puts all her children under the increased risk of developing a viral condition. The risk is further aggravated by the fact that flu is highly contagious and can spread across the entire family once developed by one of its members, thus complicating the treatment process.
Plan
The plan for management of the primary diagnosis includes the treatment of fever, ache, and soreness, as well as rest and appropriate changes in food and liquid intake. The patient is recommended to proceed with soft foods as a primary dietary choice as long as the unpleasant sensation during swallowing persists. He is also advised to increase the daily intake of fluids in order to maintain the necessary level of hydration of the lower respiratory system and prevent the formation of mucus later in the course of illness.
The fever can be treated with ibuprofen in order to prevent musculoskeletal pain. The patient is advised to avoid contacts with peers to contain the disease and get as much rest as possible. It is also recommended to increase the humidity of the environment (e.g. by using a humidifier) in order to prevent the development of cough and mucus formation. Finally, the patient as well as his family should be educated on the common symptoms of flu that might develop in the future (e.g. nasal congestion and cough) and provided with the information on the feasible ways of preventing and addressing them (e.g. administration of saline nasal drops).
Finally, it is important to educate John’s parents on the safety and effectiveness of the flu shots, outline the main risks associated with the viral infections, explain the principle of seasonal vaccination effects, and focus on the common misconceptions accompanying the decision to limit the vaccination practices.
Signature (first name initial, last name, RN, UIC, specialty)
The patient’s presenting problem is of moderate severity. The inquiry of patient history, as well as the physical exam, was expanded but not detailed. The decision-making is relatively straightforward. The patient is new to the practice. Therefore, the CPT billing level code is 99202.
References
Healthline. (n.d.a). Recognizing flu symptoms. Web.
Healthline. (n.d.b). Strep throat. Web.
Mayo Clinic. (n.d.). Toxic shock syndrome. Web.
WebMD. (n.d.). Tonsillitis: Symptoms, causes, and treatments. Web.