Episodic/Focused SOAP Note Template

Patient Information:

Jason, a 13-year-old male

S.

CC: “Really bad sore throat.”

Episodic/Focused SOAP Note Template

HPI: Jason is a 13-year-old male who was brought o the hospital by his mother with complaints of a really bad sore throat was well until the previous day when he developed a really bad sore throat and fever. He explains that the sore throat worsens with swallowing, and his symptoms worsen at night. He also reports fatigue. His mother gave him over-the-counter Children’s Motrin, and the fever subsided, but the sore throat persisted. He rates his pain at 7/10 on normal occasions and 9/10 during swallowing.

Current Medications: He has been on an OTC- Motrin 100mg/5mils, PO, TID since the previous day for sore throat and fever.

Allergies: Reports an allergy to pollen and dust, sneezes, and develops a runny nose. The last allergic attack was four months ago. Denies drug and food allergies

PMHx: Was diagnosed with pneumonia ten years ago and was hospitalized for a week. No hx of surgeries. All immunizations are up to date. #1 22/03/2021, # 2 22/09/2021 Pfizer-BioNTech COVID-19 Vaccine
Soc Hx: Negative drug or substance alcohol abuse. He loves bike riding and skating. A student in grade 8. Reports using safety seat belts when traveling.

Fam Hx: Mother, 45, is asthmatic. Father, 50, alive and well. Brothers (twins), 12, both healthy. Sister, 15, is obese.

ROS:

General: Denies weight loss, chills, fever, or weakness

Heent:

Eyes: Denies lachrymation, blurry vision, double vision, discharge, dry eyes, or pain.

Ears, Nose, Throat:  Denies changes in hearing acuity, otorrhea, or pain. Denies sneezing, rhinorrhea, or nasal congestion. Reports excruciating pain in the throat-worsens on swallowing

Skin:  Denies rashes, lesions, swellings, or pain

Cardiovascular:  Denies chest pain or discomfort, reports fatigue

Respiratory:  Denies shortness of breath, coughing, chest pain

Gastrointestinal: Reports decreased appetite due to pain. Denies nausea and vomiting, abdominal pain, hematuria, blood in Denies anorexia, nausea, vomiting, or diarrhea

Genitourinary:  Denies pain on urination or hematuria

Neurological:  Denies headache, syncope, ataxia, numbness, or tingling of feet and hands. Reports full bowel and bladder control with no changes

Musculoskeletal: Denies muscle or back pain, joint stiffness, or pain

Hematologic:  Denies bleeding or bruising

Lymphatics: Reports enlarged tonsils, denies other enlarged lymph nodes

Psychiatric:  Denies any mental illness

Endocrinologic:  Denies excessive sweating and cold or heat intolerance. Denies polyuria or polydipsia.

Allergies:  Denies drug allergies and history of asthma. Reports allergy to pollen and dust and develops a runny nose and itchy eyes in the past on exposure to the allergens

O.

Physical exam: HEENT: The head is normocephalic, with no rashes, lesions, or tenderness, normal hairline with no hair loss

Eyes: sclera white, no drainage, PERRLA, pupillary light reflex, no pallor

Nose: pink membrane, no drainage, no pain on sinus palpation, no nasal congestion

Ears; No drainage, TM gray with no inflammation or erythema. Hearing acuity good

Mouth: white patch on the tongue, no bleeding, lost two premolars and an incisor. Throat dry and inflamed

Neck: Trachea midline, cervical lymph nodes inflamed, palpable tonsil stones

Chest: Symmetrical rising on breathing, no rashes or lesions. No palpitations. On auscultation, no wheezes, no vesicular breaths auscultated, and the apical pulse was 98bpm. Resonance on lung percussion

Abdomen: Globular shape, no engorged veins, present bowel sounds in all quadrants, no lesions, rashes, or tenderness. No organomegaly or tenderness on palpation

Extremities: Capillary refill <+3, symmetric, warm, with a full range of motion on all extremities, peripheral pulse- 98bpm

Diagnostic results:

A pharyngeal swab for culture and sensitive to identify the causative agent and definitive treatment (Mustafa & Ghaffari, 2020)

COVID-19 tests to rule out COVID-19- The CDC recommends it when an individual presents with a sore throat, fever, or other associated symptoms

Ultrasonography and computed tomography to rule out a peritonsillar abscess

A.

Differential Diagnoses

Primary Diagnosis

The primary diagnosis is Strep throat with tonsil stones. Strep throat is an infection by the streptococcus bacteria affecting the tonsils and soft tissues around them. Mustafa and Ghaffari (2020) note that the typical signs of strep are a sudden sore throat (erythematous), pain swallowing, and fever.

In addition, there are white patches (pus-filled) on the back of the throat or tongue, a distinguishing feature from viral causes of pharyngitis. Most bacterial infections produce pus due to phagocytic activities. Pain is caused by inflammation and pus resulting from the host defenses’ reaction to the bacteria and phagocytes.

Other signs include fever, loss of appetite (due to pain), and fatigue in Strep throat (CDC, 2022). The tonsil stones are present on the right side, and both tonsils are inflamed. Tonsil stones result from exudate, food particles, or foreign particles. The fever responded to NSAIDs (Motrin), but the sore throat did not, suggesting an infection as the cause of the sore throat.

The cervical lymph nodes are also enlarged, and he complains that the sore throat pain worsens at night, typical signs of strep throat (Mustafa & Ghaffari, 2020). The presentation is typical of strep throat due to the accumulation of exudate and pus in the throat, and interferes with sleep and comfort. A physical examination of the nose, ear, eyes, and mouth eliminates other causes of the symptoms (Ball et al., 2019). These signs and symptoms and sudden onset lead to the ultimate diagnosis of Strep throat.

Differentials: 1. Peritonsillar abscess

Peritonsillar abscess is a complication of untreated tonsillitis. The disease can also occur after other untreated infections, such as gum and tooth infections. The condition is potentially life-threatening and has a chronic onset, unlike Jason’s sudden onset of symptoms. The disease also causes painful sore throats, fever, and difficulty swallowing, like Jason’s presentation (Klug et l., 2020).

However, peritonsillar abscess follows an infection, and the signs and symptoms are not of sudden onset. The CDC (2022) notes that untreated strep throat could lead to a peritonsillar abscess. The condition also presents with no white patches, tongue, or throat, and there are voice changes such as hoarseness, which is absent in Jason. These symptoms’ onset, severity, and duration rule out a peritonsillar abscess.

Differential 2: Hemophilus Influenza

Influenza is a viral infection caused by group Hemophilus influenza type A, B, or C. Khattak and Anjum (2022) note that influenza causes fever, cough, runny nose, body aches, fatigue, nausea, and vomiting. The disease can be easily confused with strep throat due to the sudden onset of symptoms such as sore throat, fatigue, and fever which are the condition’s hallmark. The disease also has a sudden onset.

The major difference between influenza and strep throat is the areas affected and the characteristic white patches in strep throat. Viral infections rarely produce pus, and influenza is a viral infection. The patient presents with white patches on the tongue, thus ruling out influenza. Furthermore, nasal congestion, cough, and rhinitis are common in influenza, and Jason does not present with any of these, hence ruling out the disease. In addition, flu symptoms respond to NSAIDs, unlike in strep throat.

Differential 3: Tonsil Stones

Tonsil stones are mineralization of debris on the surface of the tonsils. They are common in untreated tonsils but do not always follow tonsillitis (Bakar et al.., 2018). They are hard yellow or white formations on the surface of the tonsils. They are present in this patient, and the additional symptoms show that Tonsils stones cannot be the only diagnosis. Individuals do not have a fever, and pain is felt on the side with the stones. In addition, signs of an infection are also absent. Thus, this patient has tonsil stones in addition to strep throat.

Differential 4: rhinitis

Allergic rhinitis is a very common upper respiratory tract problem. Siddiqui et al. (2022) note that allergic rhinitis results from an allergic reaction to common allergens such as pollen and dust. The throat is sore and itchy in allergic rhinitis, and Allergic other symptoms include watery eyes, congestion, sneezing, and coughing.

Sore throat is not the main symptom; watery eyes, congestion, sneezing, and coughing are the most common primary presentations (Siddiqui et al., 2022). Jason presents with a painful sore throat with no nasal congestion, watery eyes, or sneezing, ruling out the diagnosis. Ruling out these differentials paves the way for managing the underlying condition.

References

  • Bakar, M. A., McKimm, J., Haque, S. Z., Majumder, M. A. A., & Haque, M. (2018). Chronic tonsillitis and biofilms: a brief overview of treatment modalities. Journal of inflammation research, 11, 329. https://doi.org/10.2147/JIR.S162486
  • Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Key points. In Seidel\’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
  • Center for Disease Control and Prevention (CDC), (2022). Pharyngitis (Strep Throat). Group A Streptococcal (GAS) Disease. https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html
  • Khattak, Z. E., & Anjum, F. (2022). Haemophilus influenzae. In StatPearls [Internet]. StatPearls Publishing.
  • Klug, T. E., Greve, T., & Hentze, M. (2020). Complications of peritonsillar abscess. Annals of clinical microbiology and antimicrobials19(1), 1-17. https://doi.org/10.1186/s12941-020-00375-x
  • Mustafa, Z., & Ghaffari, M. (2020). Diagnostic methods, clinical guidelines, and antibiotic treatment for Group A streptococcal pharyngitis: A narrative review. Frontiers in Cellular and Infection Microbiology, 10. https://doi.org/10.3389/fcimb.2020.563627
  • Siddiqui, Z. A., Walker, A., Pirwani, M. M., Tahiri, M., & Syed, I. (2022). Allergic rhinitis: diagnosis and management. British Journal of Hospital Medicine83(2), 1-9. https://doi.org/10.12968/hmed.2021.0570