HEENT Case Study B

Jane is a 19 year old college freshman who plays on her school’s soccer team. She presents to college health clinic with complaint of sore throat, fever, fatigue, aches and pains that started abruptly yesterday. She denies cough, runny nose, sinus congestion, nausea/ vomiting, and abdominal pain. A review of her record reveals that her immunizations are up to date. She has a benign PMH / FH. She has no drug allergies. Medications include OCPs.

VS: 110/64, 101.6, 88, 16

Physical Exam Findings

HEENT: PERRL, Sclera clear, conjunctiva pink without discharge; ear canals clear bilaterally, no swelling or exudate. TMs pearly grey bilaterally with clearly visible landmarks; nares clear bilaterally with no swelling, erythema or discharge visible; Pharynx erythematous with white tonsillar exudates bilaterally.

Neck: Supple with tender swollen anterior cervical lymph nodes bilaterally.

1. What additional history items are important?
2. In addition to the HEENT/neck findings given above, what additional physical exam items are important to perform and record?
3. Apply the Centor criteria. What did you get and what does that mean?
4. A diagnosis of GABHSpharyngitis is confirmed. What is your treatment plan?

Please refer to the Grading Rubric for details on how this activity will be graded.

• S Question 1
• O Question 2
• A Question 3
• P Question 4

The paper should be written in a Comprehensive Final SOAP Note (This is very important). Support your paper with 3-5 nursing articles not older than 5 yrs. Remember this is a more detailed comprehensive Soap Note So make sure to cover the Rubric Requirement and this is a Master’s level assignment which should reflex a higher degree of expectation.