soap note 2 assessment

Name:  L. A

Date: 03-16-2020

Age: 19

Sex: M

SUBJECTIVE

CC: 

 Sore throat, fever, and dysphagia

HPI: 

M. R is African American Male. He is a student of business school. He stated that he has a fever frequently for 4-5 days, and he also has a sore and painful throat. He added that the pain radiates to his ear too. He says that it is difficult for him to eat his regular meals.

Medications

No current medications.

PMH Comment by Extra, Carmante: Immunization missing

Allergies: No food and drug allergies.

Medication Intolerances: N/A

Chronic Illnesses/Major traumas: None Comment by Extra, Carmante: Should be right arm fracture secondary to sport

Past Hospitalizations/Surgeries: The patient was hospitalized four years back when he fractured his arm while playing football.

Family History

The patient's father is hypertensive for the last five years.

The patient's mother has diabetes mellitus for the last six years.

The patient has no siblings.

Social History Comment by Extra, Carmante: Diet, exercise and sleep missing. Missed sexual history.

He is single and lives with his parents. The patient does not have any siblings. He denies use of alcohol and tobacco.

ROS Comment by Extra, Carmante: Missing breast, heme, endo, GU, and psychiatric

General

The patient has swelling around his face and neck. He also reported fever but denies chills, night sweats, fatigue. He also denies any weight loss episodes. Comment by Extra, Carmante: This should be the patient reports…

Cardiovascular

No history of cardiac issues, chest pain, or palpitations.

Skin

Skin is intact; no lesions, itchiness, or redness seen.

Respiratory

He denies any SOB, difficulty in breathing, or excess sputum production.

Eyes

He refuses to have any vision issues like blur vision or glaucoma. Comment by Extra, Carmante: Proper denies

Gastrointestinal

The patient denies diarrhea, vomiting, loss of appetite.

Ears

The patient mentioned that he has ear pain but refuses to have any discharge from the ears.

Lymph nodes cervical lymph nodes are swollen. Comment by Extra, Carmante: The heading is Heme/Endo/Lymph. Heme and endo missing

Nose/Mouth/Throat

No running nose, difficulty in opening full mouth, painful throat.

Musculoskeletal

Denies muscle or joints pain while performing ROM.

Neurological

The patient refuses coordination difficulties, paralysis, tremors, and seizures. Comment by Extra, Carmante: Denies is the proper term

OBJECTIVE Comment by Extra, Carmante: Missing examination of breast, GU, musculoskeletal, neuro, and psychiatric.

Weight: 174 pounds BMI: 23.1

Temp: 103oF

BP: 121/80

Height: 6’2’’

Pulse: 71

Resp: 20

General Appearance

A cooperative African American young boy. Well oriented to time, place, and person.

Skin

Skin is warm to touch because of fever, no rashes or redness.

HEENT Comment by Extra, Carmante: You did not examine the neck and the thyroid. Any lymphadenopathy for a patient with sore throat?

Normocephalic and atraumatic head. No lesions were found with equal distribution of hair. Swelling on the face is seen, especially on the right side. Eyes: no vision issues, the conjunctiva is pink, and sclera appears white. The pain in the ear is about 5/10 on the pain scale. Nose: Nose Bridge is in the midline; the nasopharynx is moist. Mouth and throat: sore throat with enlarged tonsils that are covered with four yellow patches. Foul oral smell and drooling were seen. Comment by Extra, Carmante: You need to examine bilateral ears. Comment by Extra, Carmante: remove Comment by Extra, Carmante: How is the dentition? How is the tongue. Is patient able to swallow?

Cardiovascular

S1 is greater than S2. Comment by Extra, Carmante: You need to be thorough

Respiratory

Lung sounds are normal without any wheezing or rales. Resonance is present in all lung fields during percussion. Comment by Extra, Carmante:

Gastrointestinal

The abdomen is non-tender; no distension and bowel sounds are present in all four abdominal quadrants.

Lab tests:

Throat swab test: positive indicates streptococci.

CBC: raised neutrophils

 Diagnosis

Diagnosis:

· Acute tonsillitis is the infectious state of tonsils. Bacterial and viral infections both may lead to tonsillitis. Acute tonsillitis symptoms may last about 3 -5 days, with symptoms like odynophagia, dysphagia, drooling, bad breath, ear pain, pain, and edema in the throat. Fever, chills, swollen glands in the neck, blisters, or ulcers in the mouth or throat are also associated with tonsillitis. (Perry, 1998). Therefore, the patient’s symptoms and lab results indicate that the patient is suffering from acute tonsillitis.

Differential Diagnosis:

· Pharyngitis is the inflammation of the pharynx. Bacterial or viral infections can cause it. Sneezing, runny nose, fever, chills, general malaise are symptoms associated with pharyngitis (Weber, 2014).

· A peritonsillar abscess occurs mostly when tonsillitis is left untreated. Pus-filled pockets are formed around the tonsils. Symptoms are quite similar to tonsillitis, but they are more severe in the peritonsillar abscess. (Galioto, 2017).

PLAN

· Medications

· amoxicillin 50 mg TD Comment by Extra, Carmante: Prescription incomplete. What are the side effects of these new medications?

· Ibuprofen to ease fever and pain. Comment by Extra, Carmante: How much ibuprofen and for how long? How does the patient take Ibuprofen?

· Fluid management and bed rest are prescribed.

· Comforting warm foods and beverages

· Patient Education:

· The patient should be taught that bacterial tonsillitis may be contiguous, so the patient should be conscious that he should not share his food, utensils, etc. with his family. To avoid reoccurrence, the patient should be taught infection controlling techniques, e.g., hand washing.

· Follow up

· After seven days of the antibiotic course, the patient will be re-examined for symptoms, enlarged tonsils. Also, a throat swab is recommended. Comment by Extra, Carmante: When does the patient seek emergent care?

References Comment by Extra, Carmante: Please review APA format for references

Perry.M, Whyte. A (1998). "Immunology of the tonsils." Immunology Today (Review). 19 (9): 414–21. doi:10.1016/S0167-5699(98)01307-3. PMID 9745205. Comment by Extra, Carmante: Reference is outdated.

Galioto N.J. (2017). "Peritonsillar Abscess." American Family Physician. Retrieved from:95 (8): 501–506. PMID 28409615.

Weber. R (2014). "Pharyngitis." Primary Care. 41 (1): 91–8. DOI: 10.1016/j.pop.2013.10.010. PMC 7119355. PMID 24439883.

Criteria

Points

Competent

Need Improvement

Not Acceptable

Score

Subjective (35 points)

Provides complete, concise, and accurate information which is well organized and easy to understand.

Provides most of the pertinent information but is not well organized and/or is slightly challenging to understand. May be missing pertinent negative information (e.g., patient denies…).

Limited or no summary of pertinent information, is organized poorly, contains inaccurate information, and/or is difficult to understand.

Chief complaint

5

5

3

1

5

HPI

10

10

8

6

10

Relevant PMH & FH

5

5

3

1

3

ROS

10

10

8

6

8

Currents: Allergies, Meds/OTCs, Tobacco, Immunizations, Diet, Exercise, Sleep

5

5

3

1

3

Objective (40 points)

Provides complete, concise, and accurate information which is well organized and easy to understand.

Provides most of the pertinent information but is not well organized and/or is slightly challenging to understand. May be missing pertinent negative information (e.g., patient denies)

Limited or no summary of pertinent information, is organized poorly, contains inaccurate information, and/or is difficult to understand.

General survey (Describe the state of the patient at the time of the examination)

10

10

8

6

10

Vital signs, wt., BMI

10

10

8

6

10

Physical exam-systematic, organized and thorough and related to the reason of the visit

20

20

18

16

18

Diagnosis/ Differentials Diagnosis (10 points)

Main diagnosis/ Differentials Diagnosis is supported by the objective and subjective assessment and rationale for choosing the diagnosis is supported by the evidence

Main diagnosis/ Differentials Diagnosis is supported by the objective and subjective assessment but the rationale for choosing the diagnosis is not supported by the evidence

Main diagnosis/ Differentials Diagnosis is not supported by the objective and subjective assessment and the rationale for choosing the diagnosis is not supported by the evidence

Diagnosis/ (Assessment)

5

5

3

1

5

List of differentials supported by S+O findings (5 points)

Must provide 3 differential diagnoses with one citation for each diagnosis.

5

5

3

1

5

Plan of care (10 Points)

Complete and appropriate plan for the main problem and other active problems. Includes pharmacologic and/or non-pharmacologic and/or complete sig components.

Mostly complete and appropriate plan for the main problem and other active problems. May be missing appropriate non-pharmacologic treatments and/or sig components.

Missing or inappropriate treatment plan for the main problem and other active problems.

Diagnostic tests/therapies/medications

5

5

3

1

3

Follow-up/Pt. Education and Health Promotion

5

5

3

1

3

References (5 Points)

Provides a complete and appropriate list of references that are in APA format.

References listed are appropriate (i.e. guidelines or primary), but not complete and some may be missing. Not APA formatted.

References missing or very limited. References listed are inappropriate (i.e. tertiary) and/or not relevant.

References

5

5

3

1

3

Total

100

86