Focused SOAP Note-Sore Throat Essay
Focused SOAP Note-Sore Throat Essay
Subjective Data
Chief complaint: throat pain for two days
History of Presenting Illness: Jason is a 13years old male accompanied by his mother complaining of throat pain for two days. The pain is of acute onset, especially at night. The child reports that swallowing triggers the pain and does not resolve despite taking the children’s Motrin. However, the pain does not radiate. The associating symptoms are generalized body weakness, fever, mild headache, eye itchiness, and non-productive cough. However, the child denies running nose, ear pain, ear discharge, chest pain, wheezing, difficulties in breathing, and tachypnea. Focused SOAP Note-Sore Throat Essay
Current Medications:
Motrin for fever and pain
Prednisone 5mg PO PRN for allergy
Allergies: the patient develops hives after exposure to fur and dust. He takes prednisone 5mg PO PRN to relieve the allergy symptoms. He denies food and drug allergies.
PMH: the mother reports that the child has had no significant chronic illnesses since childhood. He has never has a hospital admission and has never had a blood transfusion. His immunization schedule is up to date. His last influenza vaccine was six months ago and booster tetanus three months ago. He denies undergoing a major and minor surgical procedure.
BUY NOW A PLAGIARISM-FREE PAPER HERE
Social History: the child lives with his parents and two siblings. He is in grade six and performs exemplary well in schoolwork. He relates well with his parents, teachers, siblings, and classmates. He enjoys playing basketball and watching cartoon movies. The child wears a safety belt while in the car and puts on a helmet while riding a bicycle.
Family History: Jason is the firstborn in his family. His parents, siblings, and grandparents are alive and healthy. There is no family history of chronic diseases.
Review Of Systems
General: the child denies unexplained weight change and night sweats.
Skin: the child does not have a skin rash, easy bruising, or itching.
Cardiovascular: the child reports awareness of heartbeat when he has a fever. However, he denies chest pain, orthopnea, lower limb swelling, and syncope.
Gastrointestinal: the child had one incidence of vomiting post-prandial and it was non-projectile. Vomiting is associated with loss of appetite. However, he denies abdominal pain, diarrhea, reflux, and constipation.
Genitourinary: the child denies dysuria, hematuria, polyuria, and urine incontinence.
Neurological: the child has a mild headache. However, he denies dizziness, syncope, paralysis, ataxia, numbness, tingling in the extremities, and change in bowel or bladder control.
Musculoskeletal: the child denies back pain, muscle spasm, joint pain, and stiffness.
Hematologic: the child denies bleeding tendencies, anemia, and easy bruising.
Lymphatic: denies enlarged nodes and splenectomy.
Psychiatric: the child denies loss of memory and concentration, sleeping disturbances, sadness, and irritability. Focused SOAP Note-Sore Throat Essay
Endocrinology: the child denies sweating, cold or heat intolerance, polyuria, and polydipsia.
Objective Data
General examination: the child is alert and oriented. He looks healthy for his height, weight, and age. He has cervical lymphadenopathy and his lips are dry. However, he has no pallor, jaundice, cyanosis, and edema.
Vitals: his temperature is at 39.6 degrees Celsius, blood pressure at 100/68mmHg, the pulse rate at 100 beats per minute, and respiratory rate at 28 beats per minute.
HEENT: the patient has redness of the eyes bilaterally, swollen tonsil gland 2+ and are erythematous, and right tonsil stones. In addition, he has white patches on his tongue and palatal petechiae exudate.
Respiratory: the patient has tachypnea; the airway is patent with asymmetrical chest expansion. There are no masses, swelling, or scars on the chest. There is a resonant percussion note. The lung fields are clear.
Cardiovascular: the heart is at the 5th ICS MCL, the heart sounds S1 S2 is present. There is a pan-systolic murmur. The pulse rate is present and is irregularly regular.
Diagnostic test: according to Brkic, et al, (2021), rapid antigen detection test for group A streptococcus and throat swab for culture and sensitivity is the standard criterion for diagnosis in patients with throat symptoms. Imaging and blood tests are not recommendable for accurate diagnosis.
Assessment
The patient presents with throat pain, mild headache, fever, malaise, mild headache, eye itchiness, and non-productive cough. On examination, he has a fever, tachypnea, tachycardia, and murmurs. In addition, he has conjunctivitis, oral thrush, and erythematous tonsil gland. From these signs and symptoms, he has an infection of the throat. Therefore, my differential diagnoses are pharyngitis, epiglottitis, laryngitis, scarlet fever, and diphtheria.
Pharyngitis is the inflammation of the pharynx and oral-tonsil sphere. The causes are viral, fungal, and bacterial infections. Group A streptococcus is the most common bacterial infection of the throat (Brkic, et al, 2021). Other causes of pharyngitis are neoplasia, toxins, and trauma. Clinical presentations are fever, cervical lymphadenopathy, sore throat, tonsilar exudate, and non-productive cough. This is the patient’s probable diagnosis because he presents with similar signs and symptoms.
Epiglottitis is the inflammation of the oropharynx and supraglottic region. Causes of epiglottitis are bacteria, viral, and fungal infections. The signs and symptoms are fever, mild cough, irritability, respiratory distress, tachycardia, muffled voice, tripod position, and drooling of saliva (Sideris, et al, 2021). However, this is not the patient’s diagnosis because he does not present with a tripod position and drooling of saliva.
Laryngitis is a self-limiting inflammation of the larynx. It is a common cause of upper respiratory tract infections. The causes of acute laryngitis are vocals misuse, infectious agents, and exposure to noxious agents. Clinical presentations of laryngitis are dysphagia, GERD, rhinorrhea, postnasal discharge, sore throat, congestion, fatigue, and malaise (Shin, et al, 2021). However, this is not the patient’s diagnosis because there is no change in his voice, and has no symptoms of GERD and upper respiratory tract infection.
Scarlet fever is an exudative infection of the throat caused by streptococcal pyrogenic exotoxins produced by group A beta hemolytic streptococci. It presents with fever, inflammation of the throat, headache, chill and rigors, nausea, vomiting, and myalgia. Physical findings are fever, tachycardia, whitish petechiae, and red papillae on the soft palate (Lamagni, et al, 2018). The bacteria infection is usually from nasal, ears, skin, and mouth discharge. Scarlet fever is common in school going children due to recurrent upper respiratory tract infections. However, it is not the actual diagnosis because the patient denies running nose, ear pain, ear discharge, and tachypnea.
Diphtheria is a communicable upper respiratory tract infection whose mode of transmission is through air droplets. It is common in school going children less than 12 years old. However, patients living in overcrowded environments, immunosuppression, and incomplete immunization are at risk of the infection. Clinical presentations include malaise, fever, headache, sore throat, cervical lymphadenopathy, and dyspnea (Clarke, et al, 2019). Despite patients having similar symptoms, it is not the actual diagnosis because he is 13years and fully immunized.
Chief complaint: throat pain for two days
History of Presenting Illness: Jason is a 13years old male accompanied by his mother complaining of throat pain for two days. The pain is of acute onset, especially at night. The child reports that swallowing triggers the pain and does not resolve despite taking the children’s Motrin. However, the pain does not radiate. The associating symptoms are generalized body weakness, fever, mild headache, eye itchiness, and non-productive cough. However, the child denies running nose, ear pain, ear discharge, chest pain, wheezing, difficulties in breathing, and tachypnea. Focused SOAP Note-Sore Throat Essay
Current Medications:
Motrin for fever and pain
Prednisone 5mg PO PRN for allergy
Allergies: the patient develops hives after exposure to fur and dust. He takes prednisone 5mg PO PRN to relieve the allergy symptoms. He denies food and drug allergies.
PMH: the mother reports that the child has had no significant chronic illnesses since childhood. He has never has a hospital admission and has never had a blood transfusion. His immunization schedule is up to date. His last influenza vaccine was six months ago and booster tetanus three months ago. He denies undergoing a major and minor surgical procedure.
Social History: the child lives with his parents and two siblings. He is in grade six and performs exemplary well in schoolwork. He relates well with his parents, teachers, siblings, and classmates. He enjoys playing basketball and watching cartoon movies. The child wears a safety belt while in the car and puts on a helmet while riding a bicycle.
Family History: Jason is the firstborn in his family. His parents, siblings, and grandparents are alive and healthy. There is no family history of chronic diseases.
Review Of Systems
General: the child denies unexplained weight change and night sweats.
Skin: the child does not have a skin rash, easy bruising, or itching.
Cardiovascular: the child reports awareness of heartbeat when he has a fever. However, he denies chest pain, orthopnea, lower limb swelling, and syncope.
Gastrointestinal: the child had one incidence of vomiting post-prandial and it was non-projectile. Vomiting is associated with loss of appetite. However, he denies abdominal pain, diarrhea, reflux, and constipation.
Genitourinary: the child denies dysuria, hematuria, polyuria, and urine incontinence.
Neurological: the child has a mild headache. However, he denies dizziness, syncope, paralysis, ataxia, numbness, tingling in the extremities, and change in bowel or bladder control.
Musculoskeletal: the child denies back pain, muscle spasm, joint pain, and stiffness.
Hematologic: the child denies bleeding tendencies, anemia, and easy bruising.
Lymphatic: denies enlarged nodes and splenectomy.
Psychiatric: the child denies loss of memory and concentration, sleeping disturbances, sadness, and irritability.
Endocrinology: the child denies sweating, cold or heat intolerance, polyuria, and polydipsia.
Objective Data
General examination: the child is alert and oriented. He looks healthy for his height, weight, and age. He has cervical lymphadenopathy and his lips are dry. However, he has no pallor, jaundice, cyanosis, and edema. Focused SOAP Note-Sore Throat Essay
Vitals: his temperature is at 39.6 degrees Celsius, blood pressure at 100/68mmHg, the pulse rate at 100 beats per minute, and respiratory rate at 28 beats per minute.
HEENT: the patient has redness of the eyes bilaterally, swollen tonsil gland 2+ and are erythematous, and right tonsil stones. In addition, he has white patches on his tongue and palatal petechiae exudate.
Respiratory: the patient has tachypnea; the airway is patent with asymmetrical chest expansion. There are no masses, swelling, or scars on the chest. There is a resonant percussion note. The lung fields are clear.
Cardiovascular: the heart is at the 5th ICS MCL, the heart sounds S1 S2 is present. There is a pan-systolic murmur. The pulse rate is present and is irregularly regular.
Diagnostic test: according to Brkic, et al, (2021), rapid antigen detection test for group A streptococcus and throat swab for culture and sensitivity is the standard criterion for diagnosis in patients with throat symptoms. Imaging and blood tests are not recommendable for accurate diagnosis.
Assessment
The patient presents with throat pain, mild headache, fever, malaise, mild headache, eye itchiness, and non-productive cough. On examination, he has a fever, tachypnea, tachycardia, and murmurs. In addition, he has conjunctivitis, oral thrush, and erythematous tonsil gland. From these signs and symptoms, he has an infection of the throat. Therefore, my differential diagnoses are pharyngitis, epiglottitis, and laryngitis.
Pharyngitis is the inflammation of the pharynx and oral-tonsil sphere. The causes are viral, fungal, and bacterial infections. Group A streptococcus is the most common bacterial infection of the throat (Brkic, et al, 2021). Other causes of pharyngitis are neoplasia, toxins, and trauma. Clinical presentations are fever, cervical lymphadenopathy, sore throat, tonsilar exudate, and non-productive cough. This is the patient’s probable diagnosis because he presents with similar signs and symptoms.
Epiglottitis is the inflammation of the oropharynx and supraglottic region. Causes of epiglottitis are bacteria, viral, and fungal infections. The signs and symptoms are fever, mild cough, irritability, respiratory distress, tachycardia, muffled voice, tripod position, and drooling of saliva (Sideris, et al, 2021). However, this is not the patient’s diagnosis because he does not present with a tripod position and drooling of saliva. Focused SOAP Note-Sore Throat Essay
Laryngitis is a self-limiting inflammation of the larynx. It is a common cause of upper respiratory tract infections. The causes of acute laryngitis are vocals misuse, infectious agents, and exposure to noxious agents. Clinical presentations of laryngitis are dysphagia, GERD, rhinorrhea, postnasal discharge, sore throat, congestion, fatigue, and malaise (Shin, et al, 2021). However, this is not the patient’s diagnosis because there is no change in his voice, and has no symptoms of GERD and upper respiratory tract infection.
References
Brkic, F. F., Besser, G., Janik, S., Gadenstaetter, A. J., Parzefall, T., Riss, D., & Liu, D. T. (2021). Peaks in online inquiries into pharyngitis-related symptoms correspond with annual incidence rates. European Archives of Oto-Rhino-Laryngology, 278(5), 1653-1660.
Clarke, K. E., MacNeil, A., Hadler, S., Scott, C., Tiwari, T. S., & Cherian, T. (2019). Global epidemiology of diphtheria, 2000–2017. Emerging infectious diseases, 25(10), 1834.
Lamagni, T., Guy, R., Chand, M., Henderson, K. L., Chalker, V., Lewis, J., … & Johnson, A. P. (2018). Resurgence of scarlet fever in England, 2014–16: a population-based surveillance study. The Lancet Infectious Diseases, 18(2), 180-187.
Shin, J. W., Kim, S. W., Park, S. W., & Kim, B. H. (2021). A Case Report of Acute Laryngitis with Auricular Lesion: Herpes Zoster Infection with Isolated Vagus Nerve Involvement and Vocal Fold Paresis. Korean Journal of Otorhinolaryngology-Head and Neck Surgery, 64(3), 188-191.
Sideris, G., Papadimitriou, N., Korres, G. F., Karaganis, A., Maragkoudakis, P., Nikolopoulos, T., & Delides, A. (2021). Clinical and Microbiological Factors Associated With Abscess Formation in Adult Acute Epiglottitis. Annals of Otology, Rhinology & Laryngology, 00034894211051817. Focused SOAP Note-Sore Throat Essay
| Sample Episodic/Focused SOAP Note
Focused SOAP Note for a patient with chest pain S. HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms. Medications: Lisinopril 10mg, Omeprazole 20mg, Norvasc 5mg PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years Allergies: PCN-rash; food-none; environmental- none Immunizations: UTD on immunizations, covid vaccine #1 1/23/2021 Moderna; Covid vaccine #2 2/23/2021 Moderna ROS VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70” General–Pt appears diaphoretic and anxious Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted. Gastrointestinal–The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation. Focused SOAP Note-Sore Throat Essay Pulmonary– Lungs are clear to auscultation and percussion bilaterally Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines) A. Differential Diagnosis: 1) Myocardial Infarction (provide supportive documentation with evidence based guidelines). 2) Angina (provide supportive documentation with evidence based guidelines). 3) Costochondritis (provide supportive documentation with evidence based guidelines). Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction |
A.
Differential Diagnosis:
1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).
BUY NOW A PLAGIARISM-FREE PAPER HERE
2) Angina (provide supportive documentation with evidence based guidelines).
3) Costochondritis (provide supportive documentation with evidence based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
1. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Case Study: Case Study 2: Focused Throat Exam Jason, a 13 year old male comes in with Mom complaining of painful swallowing. Started yesterday as a “really bad sore throat” made worse with swallowing. He reports feeling very tired. His Mom gave him over-the-counter Children’s Motrin which made his fever better but did not help sore throat. Focused SOAP Note-Sore Throat Essay
He reports his symptoms are especially, worse during nighttime. His tonsils are 2+ and erythematous, tonsil stones are present on the right side. He has white patches on his tongue. Consider: • Consider what history would be necessary to collect from the patient. • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis? • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. Instructions: 1) Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. 2) Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each. 3) 3 references ( one is provided ) Reference 1 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, 563627. https://doi.org/10.3389/fcimb.2020.563627 References must be within the last 5 years. I have attached the format and a sample. Focused SOAP Note-Sore Throat Essay
