ALBANY STATE UNIVERSITY COLLEGE OF SCIENCE AND HEALTH PROFESSIONS FAMILY NURSE PRACTITIONER PROGRAM Episodic Care In or!

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STUDENT NAME$ A%e&ander 'arren PT. INITIALS$ R.I. RACE$ ' AGE$ ++ SE/$ F DATE$ (()(*)+,(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 pain 6% "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$ Si2ni ican" 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 di ic6%". 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. OB0ECTIVE
BP$ ((=)=> P$ ?+ R$ (> TEMP$ (,,.HT$ =(@ 'T$ (+= BMI$ +-.>

Per"inen" P#1sica% E&a!$

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 (. Vira% URI. (. +. S"rep "#roa".

-. F%6.

+. -. ASSESSMENT (. PLAN (. Visco6s Lidocaine +A (* !% s3is# and s3a%%o3 e4er1 o6r #o6rs prn. +. T6ssione& * !% "3ice a da1 prn co62#. -. OTC T1%eno% prn e4er5 ac#es5 and pain. B. P6s# %6ids and res". *. Depo8Medro% B, !2 inCec"ion in o ice "oda1. Vira% URI.

HEALTH PROMOTION ISSUES$ Co6nse%in2$ 'ear sa e"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$ DDDDDDDDD