week #6 Narrative SOAP Note. Analysis of the subjective portion.

Week #6 Narrative Soap Note
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Analysis of the subjective portion
Bart reported severe of sore throat and the symptoms have lasted for the past 3 days and the fever has not resolved, which has necessitated using ibuprofen, a non-steroidal anti-inflammatory agents. The data and information is obtained from the questioning of the mother and Bart where the findings of the physical examination and the results of the complementary studies are inked to the subjective data. This item narratively describes the current condition of the patient including the relevant data concerning the sore throat, pain and headache.
Subjective Data:
Chief Complaint (CC): Patient reports severe of sore throat that has lasted for 3 days along with headache, fatigue, and abdominal discomfort.
Location: Throat, abdomen and head
History of Present Illness (HPI): Mrs. Epstein has taken her 11-year-old son, Bart to the pediatric clinic as Bart has complained of headaches and other symptoms.
Medications: Bart has taken ibuprofen for his fever and headache.
Analysis the objective portion
This section compiles the findings from physical examination, vital signs, general appearance, and the physical exam findings. The patient has no other major health problem, but he has clear drainage from nose, exudates on tonsils enlarged lymph nodes, pain in the left upper abdominal region including the spleen as well as fever and headache. To obtain patient data with thoroughness, truthfulness and accuracy, is necessary to develop their analytical capacity to identify problems and to carry out action plans efficiently. Recording data about the patient's health status is based on the physical examination and as the temperature is 101 and above 100.4, this confirms there is a fever.
Objective Data:
Physical Exam:
Vital signs: Height: 54 inches, weight: 80 pounds, temp: 101, HR 88; RR 20; BP 108/70
General: The patient is slouched on the chair falling asleep
Nose and Throat: The patient has clear drainage from his nose; erythematous, exudates on tonsils
Lymph Nodes: Palpable posterior and anterior cervical nodes as well as occipital and epitrochlear nodes.
Spleen: Enlarged 2 cm below Left Costal Margin (LCM) with pain on palpation of Left upper quadrant (LUQ).
Assessment:
Priority diagnosis
* Exudative tonsillitis and sore throat
* Addressing headache, fever and fatigue
* Swollen or enlarged lymph nodes
* Improving abdominal discomfort , especially around the spleen
Differential Diagnosis
* Infectious Mononucleosis
Diagnosis rule in as by evidenced by sore throat headache, fatigue, and abdominal discomfort. After examination he has erythematous, exudates on tonsils, palpable posterior and anterior cervical nodes as well as occipital and epitrochlear nodes (Burns et al., 2017). The spleen is enlarged 2 cm below LCM with pain on palpation of LUQ.
* Streptococcal Pharyngitis
This is characterized by sore throat, fever, red tonsils, swollen lymph nodes and headache. Diagnosis, rule-out as there is negative throat culture and there is no abdominal pain.
* Herpangina
This is characterized by small mouth and throat ulcers, where the infection may ...