differential dx and etc

SOAP Note Week Three: Acute Pharyngitis

Student

United States University

FNP592: Common Illnesses Across the Lifespan

Professor

November 14, 2022

SOAP Note Week three: Acute Pharyngitis

ID:

Client’s Initials: J.K Age: 68 Race: Hispanic Gender: Male Date of Birth: November 1, 1954

Marital Status: Married

The patient presented to the clinic accompanied by daughter.

Subjective:

CC: "sore throat that started 3 days ago"

HPI:

The 68-year-old Hispanic male presents to the clinic with complaints of sore throat associated with neck pain and trouble swallowing. The onset of the symptoms was 3 days ago. Patient denies cough, fever or chills, runny nose, nasal congestion, nausea and shortness of breath. He denies sick contacts. He took COVID test this morning and it is negative. He has not taken any medication for the symptoms.

Past Medical History:

· Medical problem list: Hypertension, Diabetes, Hypothyroidism and Hyperlipidemia

· Preventative care: Annual influenza vaccine, complete COVID vaccine, eye, and hearing screening every year

· Surgeries: None

· Hospitalizations: no history of hospitalization.

Allergies: Has no known allergies

Medications: Metformin 500mg 2 times a day for diabetes, Lisinopril 40 mg once a day, Atorvastatin 20mg once daily, Levothyroxine 50mcg once daily

Family History: history of diabetes (father-deceased), hypertension (mother-deceased)

Social History: The patient is married, and he lives with his wife and children. He does not smoke cigarettes or take alcohol. He is a Catholic and attends church every Sunday. He has dogs that he walks in the park every morning.

Review of System

Constitutional: Denies fever, chills, fatigue or weight changes

Head/Eyes/Ears/Nose/Mouth: Denies headaches, eye pain or discharge, no ear pain, nasal congestion, rhinorrhea or mouth sores

Throat: Complaints of sore throat, neck pain and pain when swallowing.

Cardiovascular: Denies report chest pain, SOB, palpitations, or chest pressure

Pulmonary: Denies shortness of breath, cough, wheezing, or chest wall pain with breathing

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

Neurological: denies dizziness, headache, seizures, problems, weakness

Psychiatric: Denies depression, anxiety, mood swings, memory loss, or insomnia

Hematologic/Lymphatic denies any swellings

Allergic/Immunologic: Denies allergies, denies frequent infections

Objective

Vital Signs: HR-76 BP-120/80 Temp-98F RR-18 SpO2-99% Pain-5/10 pain in the throat

Height- 167.6cm Weight -91kgs BMI – 32.44kg/m2

Physical Exam

General: Well-developed, obese, age appropriate. Well groomed, interactive in no acute distress. Vitals reviewed and stable.

Ears: Right and left ear: tympanic membrane is gray, non-bulging and freely mobile. No discharge, no foreign body noted on external canal.

Nose: Nares patent bilaterally. No epistaxis, rhinorrhea, purulent discharge, sinus tenderness or deviated nasal septum noted.

Oral cavity and pharynx: lips, teeth, and gums are in good general condition. Posterior oropharynx has erythema but no exudate, lesions, or cobblestoning.

Neck: No lymphadenopathy, neck tenderness, diffuse enlargement of the thyroid noted

Pulmonary: Clear to auscultation to all lung fields. No shortness or breath, labored breathing, or use of accessory muscles noted.

Cardiovascular: Normal S1 and S2. No murmurs. Rhythm is regular. There is no peripheral edema, cyanosis, or pallor. Extremities are warm and well perfused, without clubbing, cyanosis or edema. Capillary refill is less than 2 seconds.

Extremities: No palpable cords and there is no pain with palpation. Digits and nails are normal.

Assessment

Differentials

1.

2.

3.

Diagnosis

1. Acute pharyngitis

Plan

Diagnostics:

Treatment:

Education

Follow Up:

References