Episodic SOAP Note for Sore Throat Paper

Episodic SOAP Note for Sore Throat Paper

Week 5: Episodic/Focused SOAP Note

Patient Information:

Name: Lily

Age: 20 years

Gender: female

Episodic SOAP Note for Sore Throat Paper

Subjective

CC: Sore throat for three days

HPI: Lily has come to the clinic with complaints of a sore throat that has been there for three days. She has visited the clinic because her classmates in the campus have been having similar illness for the past two weeks. The sore throat is associated with runny nose, mild pain during swallowing, and a slight headache. She reported no hearing loss, facial pain, facial pressure, or nasal congestion. She also reported that today morning she woke up with a slightly hoarse voice and decreased appetite but with no breathing difficulties. She has no cough, chest pain, or snoring while sleeping

Current Medications: occasional use of  over the counter ibuprofen for dysmenorrhea

Allergies: She has no allergies to food or drugs that are known. No intolerance to food is reported.

Past Medical and Surgical History: The patient has no major past medical illnesses or surgeries. Her most recent flu shot was a year ago. She can’t remember her last tetanus toxoid vaccination. She reported receiving vaccination against measles, diphtheria, and pertussis during childhood

Social History: She stated taking alcohol twice this year during parties but there is no history of habitual drinking. She neither uses recreation drugs nor smoke tobacco. She exercises regularly every morning for at least half an hour. Her hobbies and interest include biking and reading novels.

Family History: She is the last born in a family of 3 children. There are no known genetic diseases in the family. The mother is an hotelier while the father works at the local school. The paternal and maternal grandparents are alive. The paternal grandfather is on management for a psychiatric illness.

Review of Systems:

  • GENERAL: no fever, weight loss of night sweats
  • HEENT: no history of head and neck trauma, no vision loss, no loss of smell or taste sensations
  • RESPIRATORY: no difficulty in breathing, no chest pain
  • CARDIOVASCULAR: no palpitation, no edema of the face and extremities, no chest discomfort
  • GIT: no abdominal pain, no nausea, no vomiting, no change in bowel frequencies, occasional heartburns after cessation of menses
  • GUT: no urinary frequencies, urgency, or polyuria; last menstrual period was 22 days ago, regular menses lasting 3 days with no menorrhagia, no pregnancies but sexually active, practices protective safe sex
  • MUSCULOSKELETAL: no joint or muscle pain or weakness, no joint stiffness, no back pain
  • HEMATOLOGIC: no menorrhagia, no nose bleeding, no easy fatigue or syncope,

Objective

General and Mental Status: the patient is well oriented to time, place, and person. She interacts well with the clinician; the mood is elated while the affect is appropriate.

Vital Signs: BP 102/78 mmHg, Temp 98.50F, RR 17, HR 66

Nutritional: Weight 61kgs. Height 179 cm

HEENT: Head: no bruises, no scars; Eyes: pupils equal round and reactive to light bilaterally, no redness;

Ears: no hearing loss, external auditory meatus is clear with no wax impaction, Weber’s test revealed no lateralization, Rinne’s test is positive, tympanic membrane is present, not bulging, not erythematous;

Nose: no bleeding, no polyps, there is clear watery drainage; both nostrils are clear;

Throat & Mouth: The voice is slightly hoarse, the oral cavity is of good hygiene, no ulcers, no oral or pharyngeal thrush, no halitosis, normal dentition, the palatine tonsils are mildly enlarged (grade II tonsillar enlargement), no peritonsillar exudate, no tonsilolith, the pharynx is erythematous, the uvula is present and not enlarged, there is no cleft palate;

Neck: no scars, no sinuses, there are bilateral tender cervical lymphadenopathy in the anterior triangle, no submental or submandibular lymphadenopathy

RESPIRATORY SYSTEM:

Inspection: normal bilateral chest wall movement with breathing, there are no scars, masses, pectus escavatum, and pectus carinutum

Palpation: centrally positioned trachea, no areas of tenderness, bilaterally equal chest expansion

Percussion: resonant percussion note

Auscultation: normal bilateral air entry, no wheezes, no rales, no crackles

Assessment

Acute Tonsilo-pharyngitis: the throat pain, mild headache, and runny nose highly suggest the presence infection of the upper airway tract (URTI) (Dains, Baumann, & Scheibel, 2019). The absence of nasal congestion and facial pain rules out the possibility of rhinosinusitis (Ball et al., 2019). The presence of erythematous pharynx and enlarged inflamed palatine tonsils supports the likelihood of acute tonsilopharyngitis.

The pain during swallowing (odynophagia) shows an obstruction in the throat that is caused by the tonsillar enlargement. The symptoms have been present for three days. The presence of sick contacts (campus classmates) highly suggests a viral etiology of the upper respiratory symptoms. Absence of cervical adenopathy in the posterior neck triangle and lack of evidence of immunosuppression makes the diagnosis of infectious mononucleosis less likely.

Reflux Laryngitis: the hoarseness of voice, the presence of occasional heartburns, and history use of NSAID (Ibuprofen) support the possibility of a recurrent laryngitis. NSAIDS are associated with increased gastric acid production and reflux into the esophagus and the throat. This can cause throat and laryngeal irritation and cause reflux laryngitis

Coronavirus Disease-19: the sore throat and sick contacts (Singhal, 2020) in the past two weeks. However, there are no muscle pains, taste or smell sensation loss, and fever

Croup: Hoarse voice and upper respiratory symptoms suggest the possibility of tracheolaryngitis. However, the patient was vaccinated against diphtheria.

Diagnostics:

Rapid antigen detection test or rapid streptococcal antigen test – to rule out the presence of streptococcal causes of the pharyngitis; this would help prevent the squealae of post-streptococcal complications and determine the course of management.

References for Episodic SOAP Note for Sore Throat Paper

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Singhal T. (2020). A Review of Coronavirus Disease-2019 (COVID-19). Indian journal of pediatrics, 87(4), 281–286. https://doi.org/10.1007/s12098-020-03263-6