Characteristics Of Soap Analysis Notes

○ Confirmation of diagnosis is made by radiographic examination of the skull (i.e., MRI of the head)

Normocephalic atraumatic. Pupils equally round and reactive to light, extraocular motions intact. Oral cavity shows oropharynx clear but slightly dried mucosal membranes. TM (tympanic membranes) clear. Neck, supple. There is no thyromegaly, no JVD. No cervical supraclavicular, axillary, or inguinal lymphadenopathy.

He was able to tolerate PO earlier around 6am. but now denies having an appetite. Patient had very small bowel movement earlier this morning that was not normal for him. He has not passes has the morning. 'he is voiding well. Denies fevers, chills or night sweats. The pain is localized to the RLQ without radiation at this point. He has never had a colonoscopy.

No history of skin disease. Skin is pink, dry, and void of bruising, rashes, or lesions. No recent hair loss; head is normocephalic. Pupils equally reactive to light; no history of glaucoma or cataracts. Ears are in normal alignment; no history of chronic infections, hearing loss, tinnitus, or discharge. Nose and sinus history includes clear nasal discharge “since last October”, and occasional nose bleeds; states she use to get nose bleeds often as a child. Mouth and throat are absent of lesions; no bleeding gums, sore throat, dysphagia, hoarseness, or altered taste. Neck is void of pain, swelling,

Breasts: no masses, no nipple retraction, no discharge. Heart: S1 and S2, no gallops, rubs, or murmurs appreciated. Abdomen is scaphoid, soft and non-tender with positive bubble sounds. Pelvic/ Rectal: deferred as patient has recently visited her GYN for a routine Pap smear. Neurologic exam reveals normal motor strength in all muscle

The working diagnosis is that this patient is suffering from Angioedema as a result of Anaphylaxis and developing Urticaria. Angioedema is the swelling of deep layers of the skin due the accumulation of fluid, symptoms of Angioedema include swelling of the eyes, lips, hands and feet.

Cardiovascular Assessment: No visible pulsations, no heaves or lifts. Apical pulse present in the fifth intercostal space at the left midclavicular line. Auscultation of apical rate 62 beats per minute, normal rhythm regular S1 - S2 heart sounds present. Pulsations present when supine and disappear at a 45 degree angle position. Extremities are brown color without redness, cyanosis, lesions or varicosities bilaterally. Temperature warm bilaterally, Allen test was negative. Homan’s sign negative. Carotids: +2 and present bilaterally. Right Radial +2, left radial +1 , Right Brachial: +2

Onset: When did you first notice the fever? Where were you when you first began having the symptoms?

Acute tonsillitis is inflammation of the tonsils secondary to an infectious process causing painful swallowing and is more commonly attributed to a viral cause rather than bacterial (Shepherd, 2013). A physical assessment of the tonsils may reveal an increase in size with edema and erythema. This is often associated with upper respiratory symptoms like, headache and cough (Shepherd, 2013). Another diagnosis is pharyngitis. Pharyngitis is also a sore throat which is secondary to inflammation noted at the back of the throat and associated with complaints of pain when swallowing (Shepherd, 2013). Viral pharyngitis is the most common and can be contributed to the rhino or coronavirus which lasts between 5-7 days and presents with associated symptoms like cough, headache, fatigue and mild fever (Ruppert & Fay, 2015). Finally, GABHS or more commonly noted as strep throat is a potential diagnosis. This bacterial infection is most common in children and adolescents. Often individuals present with symptoms including throat pain, fever, chills, headache, cervical lymphadenopathy and exudate noted to tonsils or in the pharyngeal (Ruppert & Fay, 2015). This infectious process in younger children may also present with gastrointestinal symptoms like nausea, vomiting and abdominal pain but is not accompanied by cough or nasal

Electrodiagnostic consultation report dated 10/02/15 revealed normal study of both upper limbs and cervical paraspinals. No evidence of cervical radiculopathy. No median or ulnar neuropathy.

All cranial nerves tested within normal limits. Pt passed visual fields exam and no problems with gag reflex. Pt moved muscles evenly and bilaterally and was able to shrug shoulders and move head from side to side.

When taking these tests, doctors look for the results of defining the size of the cerebral ventricles and showing a blockage [11]. Also, examining if the cerebellar tonsils are out of position, but since Chiari is always changing, doctors use symptoms and the results of the cerebral [12]. When checking the functions controlled by the cerebellum and spinal cord, doctors watch for balance, touch, reflexes, sensation and motor skills [13]. Since the symptoms deal with these topics/skills, looking for relation between both symptoms and possible problems/conditions.

One of the main symptoms is muscle weakness and/or tiredness. Another symptom would be vomiting. Another symptom is fatigue Also another symptom can possibly be joint pain. The rest of the symptoms are headaches, nausea, fever, and sore throat.

What symptoms should I be aware of? Symptoms occur approximately 2 to 10 days after

If you are found in any of the above symptoms, do not use tips on their own home, but I will refer to your doctor or nearest hospital to diagnose the disease treatment as soon as possible.