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NR-511 Week 3 Discussion: Open Forum: SNAPPS Presentation (GRADED)
- Course
- NURSING
- Institution
- Chamberlain College Of Nursing
NR-511 Week 3 Discussion: Open Forum: SNAPPS Presentation (GRADED)
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SNAPPS ORAL PRESENTATION TEMPLATEThis template should only be used to organize your oral presentation, IT SHOULD NOT BE SUBMITTED. Knowing which antibiotic to use, allergy to sulpha or pcn
Rapid strep comes back negative but it’s clearly strep & give medication anyway
SUMMARIZE
Using a patient seen in - practicum setting, summarize - H&P into an organized & concise format. CCSore throat, cough, congestion
28 year old female.
HPI statement
using OLDCARTS dataO – Onset
Sore Throat
This is a new problem. - current episode started yesterday. - problem has
been unchanged. L – Location
Nei-r side of throat is experiencing more pain than - o-r.
D – Duration
Continuous for past 24 hours
C – Character
Maximum temperature: low grade, 99.5. - fever has been present for less than 1 day. Associated symptoms include congestion & coughing. Pertinent negatives include no ear pain or shortness of breath. Pt reports
pain as 6/10 & scratchy & sore throat, & positive for nasal congestion & cough. A - Alleviating & Aggravating factors
Swallowing makes - sore throat worse, no reported alleviating factors
R – Radiation
denies
T – Treatments
Pt tried OTC NSAIDS with mild relief
S – Severity
- pain is reported to be moderate & bo-rsome but does not distruct ADLs
Pertinent ROS
Review of Systems
Constitutional: Positive for diaphoresis & fever. Negative for chills.
HENT: Positive for congestion, postnasal drip, sinus pressure & sore throat. Negative for ear pain & sinus pain.
Respiratory: Positive for cough. Negative for shortness of breath & wheezing. Pertinent PE
BP 129/81 | Pulse 95 | T emp 37.5 °C (99.5 °F) | Ht 175.3 cm (5' 9") | Wt 114.3 kg (252 lb) | LMP 01/08/2020 | BMI 37.21 kg/m²
Physical Exam
Vitals signs & nursing note reviewed.
Constitutional:
General: She is not in acute distress.
Appearance: Normal appearance. She is well-developed & well-groomed.
She is ill-appearing. She is not toxic-appearing.
HENT:
Head: Normocephalic & atraumatic.
Right Ear: Tympanic membrane & ear canal normal.
Left Ear: T ympanic membrane & ear canal normal.
Nose: Nose normal.
Mouth/Throat:
Lips: Pink.
Mouth: Mucous membranes are moist.
Pharynx: Oropharynx is clear. Uvula midline. Posterior oropharyngeal ery-ma present.
T onsils: No tonsillar exudate. Swelling: 1+ on - right. 1+ on - left.
Cardiovascular:
Rate & Rhythm: Normal rate & regular rhythm.
Heart sounds: Normal heart sounds.
Pulmonary:
Effort: Pulmonary effort is normal.
Breath sounds: Normal breath sounds.
Lymphadenopathy :
Cervical: Cervical adenopathy present.
Skin:
General: Skin is warm & dry.
Neurological:
General: No focal deficit present.
Mental Status: She is alert & oriented to person, place, & time. NARROW
Based on - H&P key findings, identify an appropriate differential.
1.Acute pharyngitis
2.Streptococcal pharyngitis 3.Acute nasopharyngitis [common cold]
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