topic: Diagnosis for Anaphylactic shock
Christine is a 17-year-old student who has been complaining of a very sore throat for the past four days. Despite taking cold and flu medications at home, she feels that her symptoms are getting worse. She arranges an appointment with her GP. During her assessment, it was identified that Christine had severe tonsillitis. Her throat was red and inflamed and Christine was complaining of feeling very unwell and finding it difficult and painful to swallow. In addition, she had a temperature of 38.2°C(100.7). In view of her symptoms, her GP decided to refer her to the ear, nose and throat (ENT) department of the local hospital where she was admitted with a quinsy infection. She has a history of asthma and mild panic attacks but no other significant medical history. She also has no known drug allergies. Shortly after admission to the ward she was commenced on an IV Infusion of amoxicillin 1 g. Within five minutes of the infusion commencing, she developed a red rash on her face and upper chest. She also appeared to be extremely anxious and was pointing to her throat which was swollen. She was finding it very difficult to breathe and on closer examination, an audible wheeze could be heard. The staff nurse present is concerned and calls for help. Patient complain of not feeling for 4 day , fever (38.2 ), chills, sweats, home remedy hot tea, took Tylenol , Motrin, past history Anxiety ,taking medication for anxiety Zolof, history of Asthma taking albuterol inhaler PRN , labs done CBC, wbc elevated 14,000
Plan of care
- Explain what the patient is at risk for.
- Articulate safety concerns or issues at home.
- Explain 2 challenges that might prevent the patient from seeking medical care.
- Articulate all patient education for the patient and treatment plan.
- Explain an understanding of the diagnosis and treatment.
- Identify 2 short-term goals & 2 long-term goals.
- Identify 2 outcomes for the patients.
- Articulate appropriate discharge instructions for these patients.
- Articulate appropriate follow-up care.
SOAP Note :
The required elements include the following:
- Clear statement of subjective findings.
- Clear statement of objective findings.
- Clear statement of assessment findings.
- Clear statement of plan.
All information taken from another source must be included on a reference listing using the 7th edition APA.
Here is an example to look at