SOAP NOTE

SOAP Note on Sore Throat

 

Name xxx

United State University

Primary Healthcare of Chronic Client/Families Across the lifespan-Clinical Practicum

xxxx

Professor xxxxx

Datexxxx

 

 

 

 

SOAP Note on Sore Throat

Subjective Data

Client’s Initials: M.K. Sex: Male, Age: 65, Race: Caucasian. DOB 1957.

Marital Status: Married.

Patient is a reliable historian.

CC: “I have a sore throat, and difficulty swallowing x 5 days”

HPI: M.K. is a 65-year-old Caucasian male presents to the clinic with the complaints of sore throat, difficulty swallowing and some minor fatigue x 5 days. He reports that the sore throat started five days ago, and the pain could last for 4-5 hours. He rated the pain in the throat as 6 out of 10. He stated that he took over the counter Tylenol 650 mg orally every 6 hours as needed to ease the pain, which has not been effective on him. He described the pain as burning, reports pain while swallowing foods, especially solid meals worsened the pain. He also stated that, the pain radiates to the anterior cervical lymph node but doesn’t limit him from moving his neck. Patient states that he has not interacted with sick people or traveled lately. He denies fever, dizziness, or chest pains. He also denies taking any prescriptive medication or having been diagnosed with any chronic illness.

Past Medical History: Has never been diagnosed with any disease.

Surgical: Never had surgery.

Hospitalization: Never been hospitalized.

Allergies: No known allergies to medications, food, or environmental factors.

Current Medications: Not taking any medication currently.

Immunization: Up to date on all immunizations.

Vaccination: Received 2 doses of Covid-19 vaccine and 1 booster shot.

· Current Flu shot 10/10/2021.

FAMILY HISTORY

· Wife: 55-year-old alive with the history of arthritis.

· Mother: 90-year-old alive with the history of Hypertension and asthma.

· Father deceased at 82 years with a history of Hyperextension and Gout.

· Sister: 53-year-old alive and healthy.

· Brother: 50-year-old alive with a history of Asthma.

· Son: 30-year-old alive and healthy

· Daughter: 20-year-old alive and healthy.

· Grandparents: all deceased of unknown illnesses.

SOCIAL HISTORY

· Retired bank manager.

· Denies alcohol, cigarettes, or any illicit drugs.

· Married one wife and has two children.

· Lives with the family in a well-secured apartment.

· Owns 2 cars, and all have safety belts.

· Owns two pets, a cat, and a dog.

· Exercise 2-3 times a week, enjoy playing basketball with his son.

Diet: Eats regular diet with more of vegetables and fruits

Stress: No major stressors have been reported.

Spiritual/Affiliation: He is a Christian.

Review of Systems.

Constitutional: Patient is alert and oriented x 4, well-groomed and well nourished. Sits comfortably in a chair, has no weight changes, no fever or fatigue.

Head: Denies numbness, or migraines.

Eyes: Denies blurred vision, eye discharge, eye discomfort, excessive tears, or vision loss.

Ears: Denies hearing impairments, discharges, ringing, aches, or the use of hearing aids.

Nose: Denies runny nose, nasal congestion, nose bleeding, or sinus pain.

Mouth/Throat: Reports sore throat and has trouble swallowing solid foods. Denies bleeding gum, or dry mouth.

Lymph: Reports painful neck, and swollen lymph nodes.

Skin: Denies any itchy skin, lesions, bruises, or rashes.

Cardiovascular: Denies chest pain, and difficulty in breathing, heart murmurs or breathlessness.

Respiratory: Denies coughing, wheezing, or dyspnea.

Gastrointestinal: Denies nausea, vomiting, constipation, abdominal pain or diarrhea.

Genitourinary: Denies urine urgency, no dysuria.

Musculoskeletal: Denies muscular or joint discomfort or stiffness problems.

Neurological: Denies headaches, head traumas, seizures, or brain tumors, and there has been no memory loss. There are no delirium, lunacy, tremors, or numbness.

Psychiatric: Denies depression, anxiety, there are no suicidal attempts.

Allergies: No known medication, food, or environmental allergies.

OBJECTIVE DATA

Vital Signs

Temperature: 98.8, BP: 126/72, RR: 20, SpO2: 99 %, 6/10 throat pain

Height: 5’8, Weight: 150 lbs. BMI: 22.8.

Centor score 2/5 (Tonsillar exudate +1, absent cough +1, anterior cervical lymphadenopathy +1, Age > 44years -1).

Labs: Rapid antigen test for group A streptococcus- positive

Rapid influenza diagnostic test (RIDTs) – Negative

SARS-CoV-2 Rapid Antigen Test-Negative

Physical Examination

General Appearance: Patient appears to be healthy adult male, who is experiencing moderate distress due to pain in his throat.

Head: Normocephalic, hair evenly distributed, no bruises, hematoma, or lumps

Eyes: Conjunctiva is pink, sclera is white. There is no bleeding or exudate, EOMI. Anicteric. PERRLA. No allergic shiners.

Ears: Bilateral external canal and tympanic membranes is pearly gray, on the right ear, the Cone of light is 5’o clock and left is 7’o clock. Hearing is intact.

Nose: There are no polyps, no discharge, and the mucous membrane is moist. No nasal deviation noted.

Throat: Pharynx erythema with white exudate, tonsillar edema +2, and lymphadenopathy.

Neck: Tenderness noted on his anterior cervical lymph node.

 

Lungs: Clear to auscultation and percussion, without rales, rhonchi, or wheezing. Clear breathing sound in all lung field.

Cardiovascular: a regular heartbeat, a sinus rhythm with a healthy S1 and S2 but no murmur or clicking noises, no rubbing or galloping,

Gastrointestinal: Abdomen soft, all four quadrants of the bowels are functioning normally. No guarding, rebounding, or lumps noted.

Genitourinary: Bladder non tender upon palpation. No penile discharge or any disorders noted.

Musculoskeletal: Extensive range of motion and functional strength in upper and lower extremities. There is no swelling, joints pain, or muscles pain noted

Neurologic: Speech clear, Stable balance, and normal gait. Intact reflexes, symmetrical motions, and no focal impairments.

Psychiatric: Appropriate mood and tone of voice.

ASSESSMENT

Primary Differential Diagnosis

1. Streptococcal pharyngitis J02. 0- As a result of this disorder, the tonsils and throat become inflamed. Inflamed tonsil and throat pain are common signs of tonsillitis. Streptococcus group A is a prevalent cause. Antibiotics are required to prevent the development of post-streptococcal reactive arthritis (rheumatoid arthritis), which can occur if the patient is not given them. This ailment can be detected by a sore throat, fever, sensitive lymph nodes in the neck, and tonsillar exudate (Sykes et al., 2020). Because the findings of a throat swab were positive, it was ruled in.

2. Flu (influenza) J10. 1– The flu attacks the lungs, nose, and throat, among other respiratory system parts. The virus is more likely to infect children, the elderly, and persons with chronic illnesses or compromised immune systems. Symptoms of the sickness include a sore throat, fever, chills, muscular pains, cough, nasal congestion, febrile seizure, and headaches. (Czubak et al., 2021). A flu vaccination given once a year can help prevent the virus and lessen its consequences. Rapid influenza diagnostic test was negative; thus, it was ruled out.

3. COVID-19 U07.1– SARS-CoV-2 virus-induced Coronavirus Disease (COVID-19) is a disease caused by the SARS-CoV-2 virus. It’s a disease that may be hazardous. Most people infected with COVID-19 will have mild to severe symptoms and recover independently. Sore throat, headache, and loss of taste are frequent symptoms of diarrhea, fever, and cough (Czubak et al., 2021). Even though the patient had some symptoms, the SARS-CoV-2 Rapid Antigen Test was negative.

Final Diagnosis:

Streptococcal pharyngitis-As evidenced by Sore throat, Tonsillar Exudates, fatigue, and tender cervical adenopathy.

Plan:

CBC- To rule out any abnormalities with the white blood cells.

Treatment: The treatment’s goal is to prevent acute rheumatic fever by reducing the severity and duration of symptoms, as well as preventing transmission (Luo et al., 2019).

· Amoxicillin 500mg PO BID x 10 days, Dispense 20 capsules, no refills (Luo et al., 2019).

· Lidocaine oropharyngeal viscous solution (2%) 20mg/ml mix 10ml with 10ml of water gargle or spit every 4 hrs. PRN for throat pain. Quantity 1 bottle.

· Ibuprofen 400mg PO every 6 hours as needed for pain and inflammation.

· Patient instruction- take 1 capsule by mouth twice daily, for 10 days.

· Ensure adequate hydration.

· – If you experience a watery or bloody diarrhea or severe stomach pain, notify your doctor.

· Complete the prescribed antibiotic even if the symptoms subsided.

· Home Remedies

· Have more rest.

· Drink plenty of fluids with honey, lemon, or chamomile.

· Use warm salt water to gargle.

· Avoid cold/refrigerated drinks (Luo et al., 2019).

Education

· Avoid close contact (i.e., kissing, sharing of cups, etc.)

· Cover nose and mouth with a piece of tissue or serviette anytime sneezing or coughing.

· Use the elbow instead of hands to catch droplets when coughing or sneezing.

· Do not share a cup, plate, or utensil with someone who is sick.

· Spend most of the time at home to prevent others from being sick.

· Maintain regular handwashing with running water and soap for at least half a minute (Luo et al., 2019).

 

Referral: None

Follow up: Client to return to clinic if symptoms do not improve in 2 weeks or go ED if symptoms persist or worsen.

 

References

Czubak, J., Stolarczyk, K., Orzeł, A., Frączek, M., & Zatoński, T. (2021). Comparison of the clinical differences between COVID-19, SARS, influenza, and the common cold: A systematic literature review. Advances in Clinical and Experimental Medicine30(1), 109-114.

Luo, R., Sickler, J., Vahidnia, F., Lee, Y. C., Frogner, B., & Thompson, M. (2019). Diagnosis and management of group A streptococcal pharyngitis in the United States, 2011–2015. BMC infectious diseases19(1), 1-9.

Sherman, A. C., Mehta, A., Dickert, N. W., Anderson, E. J., & Rouphael, N. (2019). The future of flu: a review of the human challenge model and systems biology for advancement of influenza vaccinology. Frontiers in cellular and infection microbiology, 9, 107.

Sykes, E. A., Wu, V., Beyea, M. M., Simpson, M. T., & Beyea, J. A. (2020). Pharyngitis: Approach to diagnosis and treatment. Canadian Family Physician66(4), 251-257.

Tang, Y. W., Schmitz, J. E., Persing, D. H., & Stratton, C. W. (2020). Laboratory diagnosis of COVID-19: current issues and challenges. Journal of clinical microbiology, 58(6), e00512-20.

Wolford, R. W., Goyal, A., SY, B. S., & Schaefer, T. J. (2018). Pharyngitis.