Below is a SOAP (Subjective, Objective, Assessment, Plan) note entered into a pediatric chart. Review carefully and then answer the following questions.
**Subjective:**
Ben Smith is a 10-year-old male who presents for a sick visit at the pediatric office accompanied by his mother. He complains of a fever, sore throat, and general malaise for the past three days. His appetite has been poor, and he has had pain with swallowing. He has had occasional nausea with vomiting. His temperature has been fluctuating around 101.1°F. There has been a mild headache. He has not had any cough or rhinorrhea. He denies any shortness of breath, diarrhea, abdominal pain, or painful urination. Several children in his 5th-grade class have also been sick in the past few weeks.
**Objective:**
Vital signs:
- Temperature: 99°F
- Heart Rate: 115 beats per minute
- Respiratory Rate: 15 breaths per minute
- Blood Pressure: 110/76
- Oxygen saturation: 100% on room air
General: Well-nourished; awake and alert; oriented to place, person, and time.
HEENT:
- Head: No sinus tenderness, normocephalic, atraumatic
- Ears: Tympanic membrane intact; no erythema
- Eyes: Pupils equal, round, and reactive to light, conjunctiva without erythema
- Nose: Mucous membranes intact, without congestion
- Throat: Erythematous and edematous pharynx and soft palate, tonsils swollen with white exudate bilaterally, anterior cervical adenopathy that is tender to touch
Respiratory: Normal breath sounds, no coughing observed
Heart: Normal sinus rhythm, no murmurs
Abdomen: Nontender to palpation, nondistended, normal bowel sounds
Extremities: Upper and lower extremity joints without tenderness and with normal range of motion, no edema noted
Neurological: Awake, alert, oriented to time, place, and person. Without signs of distress.
Skin: Without rashes or ecchymosis.
**Assessment:**
Acute group A streptococcal pharyngitis without signs of rheumatic fever
**Plan:**
- Support symptoms with anti-inflammatory medications such as ibuprofen 100mg/mL 12.5 mL by mouth every 6 hours as needed for fever and general pain.
- Patient with a score of 5 using the Centor criteria. Ordered rapid strep test in office. Rapid test was positive for streptococcal antigen. No need to proceed with throat culture.
- Called prescription of amoxicillin 500mg po q12h for 10 days into the patient’s pharmacy.
- Instructed patient to remain home from school until fever-free for 24 hours.
- Instructed to call the office for worsening, persistent fever or chills, new rash, or other concerns.
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1. Define the medical terms seen in italics above. Identify the Latin and Greek word elements of the words if present.
2. Replace the underlined terms above with the appropriate medical term (10 points).
3. Identify the eponym.
4. Ibuprofen is recommended to help reduce the patient’s fever and general pain. What is the medical term for a fever-reducing medication?
5. Conjunctiva was a medical term seen in the examination of the eye. It refers to the mucous membrane that lines the eye.
- A) What is the plural form of the word?
- B) Add the suffix -itis to the term. How does that change its meaning?
