MVU NURS 629 WEEK 9 SOAP 630 Subjective History

MVU NURS 629 WEEK 9 SOAP 630 Subjective History “Sore throat/feeling feverish x 1 day” History of Present Illness A 9-year-old male presents with sore throat that started yesterday. Mom is unsure of fever because they don’t have a thermometer but has seemed “feverish.” She gave him Tylenol last night and this morning to help with the sore throat. This afternoon the school called her to pick him up because he developed a rash on his trunk. He states the rash does not itch; it has spread over the past few hours. Mom denies any new exposure to detergent, soap, or medication. No known sick contacts. Denies concurrent cold symptoms, no cough. Complains of headache and more tired than usual. Drinking fluids, slightly decreased appetite, did not eat his lunch at school today. Denies nausea or vomiting, no diarrhea. Surgeries- Denies past surgical history Medical History: Otitis media of left (2018), Acute Pharyngitis (2019) Current Medications: Flonase Allergy Relief 50mcg/act, 2 spray each nostril daily. Loratadine 10ml daily Allergies: NKDA, no food allergies; Immunizations: Vaccines reviewed. Up to date with all childhood vaccines. Due to yearly influenza vaccine, Last vision exam 2019, last dental exam 02/2020.