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8/13/2019 Episodic 3 (2)
http://slidepdf.com/reader/full/episodic-3-2 1/2
ALBANY STATE UNIVERSITY COLLEGE OF SCIENCE AND HEALTH PROFESSIONS
FAMILY NURSE PRACTITIONER PROGRAM
Episodic Care Inor!a"ion S#ee"
STUDENT NAME$ A%e&ander 'arren DATE$ (()(*)+,(-
PT. INITIALS$ R.I. RACE$ ' AGE$ ++ SE/$ F ENCOUNTER DATE$ (()(()+,(-
SUB0ECTIVE
C#ie co!p%ain")concern$ P" co!es in "oda1 co!p%ainin2 o a sore "#roa" / - da1s 3i"# e4er5 sin6s
press6re)pain5 co62#in25 snee7in25 and 2enera% co%d8%i9e s1!p"o!s.
HPI$ P" s"a"es "#a" "#ree da1s a2o s#e :e2an #a4in2 pain in #er "#roa" 3#en s3a%%o3in2 "#a" #as
pro2ressi4e%1 2o""en 3orse "o "#e poin" 3#ere s#e #as a sore "#roa" cons"an"%1. S#e s"a"es "#e e4er
:e2an 1es"erda1 and co%d8%i9e s1!p"o!s :e2an 3i"# i". S#e s"a"es #er sore "#roa" is pain6% "o "#e poin"
3#ere s#e canno" ea".
PMH$ No pas" !edica% #is"or1. N;DA. Te"an6s s#o" is 6p "o da"e.
FH$ Si2niican" or #1per"ension)#1per%ipide!ia < a"#er. O4arian CA < !o"#er.
SH$ P" is a s"6den" a" Va%dos"a S"a"e Uni4ersi"1. C6rren"%1 da"in2 "#e sa!e !a%e or "3o 1ears. S#e is
se&6a%%1 ac"i4e.
ROS$
Head)nec9$ Co!p%ains o sore "#roa" / - da1s "o "#e poin" no3 3#ere s3a%%o3in2 is diic6%". S#e
co!p%ains o sin6s press6re)pain < par"ic6%ar%1 o "#e !a&i%%ar1 sin6ses :6" denies nasa%
draina2e)con2es"ion. S#e denies an1 ear pain or 6%%ness in #er ears. S#e denies an1 :%6rred 4ision.
NEURO$ S#e denies an1 di77iness or 4er"i2o.
Cardio4asc6%ar$ P" denies an1 c#es" pain or pa%pi"a"ions.
Respira"or1$ P" denies an1 SOB. S#e does #a4e a !i%d co62# 3i"# no prod6c"ion. S#e denies an1
:6rnin2 or pain in #er c#es" 3#en s#e co62#s. Co62# #as :een presen" or "#ree da1s.
Gas"ro$ P" denies an1 cons"ipa"ion5 diarr#ea5 na6sea5 or 4o!i"in2.
OB0ECTIVEBP$ ((=)=> P$ ?+ R$ (> TEMP$ (,,.- HT$ =(@ 'T$ (+= BMI$ +-.>
Per"inen" P#1sica% E&a!$
8/13/2019 Episodic 3 (2)
http://slidepdf.com/reader/full/episodic-3-2 2/2
VSS. L6n2s c%ear. HRRR. Ma&i%%ar1 sin6ses are "ender 3i"# pa%pa"ion. Nasa% "6r:ina"es are red and
in%a!ed. Grade "3o "onsi%s no"ed 3i"# no 3#i"e or 1e%%o3 pa"c#es. Mi%d "onsi%ar and s6:!andi:6%ar
%1!p#adenopa"#1 no"ed. Pa"ien" is ac"i4e%1 co62#in2 and snee7in2 3#i%e e&a! is in pro2ress. Ears
re4ea% pear%1 2ra1 TMs. ABD non"ender.
La: Findin2s)Dia2nos"ics$ S"rep "#roa" s3a: ne2a"i4e. F%6 s3a: ne2a"i4e.
DIFFERENTIAL DISGNOSIS
(.
+.
-.
ASSESSMENT
(. Vira% URI.
PLAN
(. Visco6s Lidocaine + (* !% s3is# and s3a%%o3 e4er1 o6r #o6rs prn.
+. T6ssione& * !% "3ice a da1 prn co62#.
-. OTC T1%eno% prn e4er5 ac#es5 and pain.
. P6s# %6ids and res".*. Depo8Medro% , !2 inec"ion in oice "oda1.
HEALTH PROMOTION ISSUES$
Co6nse%in2$ 'ear sae"1 :e%" 3#en ridin2 in a car. Ens6re pro"ec"ion ro! pre2nanc1 and STDs. P"
c6rren"%1 no" 6sin2 an1 9ind o :ir"# con"ro%. Ge" 1ear%1 p#1sica% inc%6din2 e1e screen. 'ear
s6nscreen 3#i%e o6"side or e&"ended periods o "i!e.
Screenin2$ O:ser4e or c#an2es in s9in)!o%es. Year%1 pe%4ic and pap s!ears.
C#e!oprop#1%a&is$ M6%"i4i"a!in.
COMMENTS$
□ Assi2n!en" Accep"ed
□ P%ease Re8Do Fac6%"1 Ini"ia%s$
(. Vira% URI.
+. S"rep "#roa".-. F%6.