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Week 4 SOAP Note

Subjective

7/24/21 4:00 PM

ID: E K is a 50-year-old AA born on 28th Junel 19 62 presenting at the clinic looking pleasant but with a lot of information.

CC: The chief complaint of the patient was a sore throat and coughing.

HPI: The patient said that she had been coughing and having a sore throat for three days before seeking medical attention. She had never experienced such symptoms and thus does not understand what triggers the coughing, however, she does not have any problem with swallowing. The cough is dry with clear sputum, she had done a covid test and fitness exam a month ago and everything was clear.

PMH

Medical Problem list: She has not had any significant health problems recently or in the past.

Surgeries and hospitalizations: She has not had any surgery, minor or major, also she has no history of hospitalization.

Immunizations: Patient has received all childhood vaccinations, in late 2020, either November or December, she received her flu shot, she has received both shots of the COVID 19 vaccine the last shot being made on 23rd July 2021.

Allergies: The patient does not have any form of sensitivity, whether occupational, pharmaceutical, seasonal or dietary.

Medications: Currently, the patient is not under any medication.

Family History: Lacks a significant family history in relation to health.

Social History

Sleep/Stress: The patient has a regular sleep pattern with no disturbances, sleeps for a maximum of 8 hours.

Occupation, marital/relationship status & current living situation: She has a doctorate as a pharmaceutical practitioner, not married, but is dating. She has no children of her own, however, she lives with both parents along with two children.

Diet/exercise/caffeine: A significant portion of her diet entails lipids, proteins and greens. She is trying to maintain a healthy diet and lifestyle by exercising for approximately 30 to 40 minutes daily. Her routine consists of coffee in the morning and tea in the evening.

Drugs and Alcohol: No alcohol or substance use

Smoking: No vaping or smoking

Sexual/Reproductive: sexually inactive

Spiritual Affiliation: no spiritual affiliations

Review of Systems

Constitutional: The patient feels tired than usual, however, she does not complain of changes in her sleeping patterns or body temperature.

Head: Does not experience dizziness or headache.

Eyes: Does not have any problem with vision.

Ears: No ear problems.

Nose: No problem with the nose or sense of smell.

Mouth/Neck/Throat: No changes in taste or matters relating to the mouth, neck and throat, the only problem is a sore throat.

Respiratory: chest soreness.

Objective

Vital Signs:  BP 118/82, RR 15, HR 78, T 97.3 SpO2 98% 

Head: The hair is evenly distributed with no abnormalities on the head.

Eyes: everything is of normal and optimal functioning and no sensitivities or abnormalities.

Ears: Ear is functioning optimally with no foreign substance or abnormality.

Nose: Absence of perforation, inflammation and effusion.

Mouth/Throat: Absence of discharge however redness was observed in the pharnyx as well as the back of the oropharynx, also, the back of the throat had cobblestone.

Neck : Absence of thyroid nodules and non-palpable lymphoid tissue

Cardiovascular: Normal rhythm.

Pulmonary: No wheezing or rales or dullness in the lungs.

Assessment

Differential Diagnosis: 

Pharyngitis – the coughing and acute sore throat have not been witnessed for a long period. (J02.0) (McCance & Huether, 2019)

COVID-19 exposure – The patient has a negative swab, also, she is fully vaccinated against COVID-19. (Z20.822) (McCance & Huether, 2019)

Peritonsillar abscess- This is an indefinite diagnosis because it brings about blockage and difficulty in swallowing, (J36) (McCance & Huether, 2019)

Final Diagnosis: Pharyngitis / ICD Code: J02.0 (ICDDATA10, 2021)

Plan

Diagnostics:

A culture will be done for a throat swab, along with sensitivity.

Treatment:

For a positive result, the patient will be prescribed 500mg of oral amoxicillin for ten days. If the results turn out negative, more viral tests shall be carried out.

Education:

If symptoms persist, a day off and good rest will help.

Patient might be dehydrated, increased fluid intake might help.

Gargling warm water with saline is a good remedy to alleviate the pain and lozenges.

Avoiding consumption of extra salty and acidic food will help alleviate the symptoms.

References

Ashurst, J. V. (2021, 7th May). Streptococcal Pharyngitis. StatPearls [Internet].

https://www.ncbi.nlm.nih.gov/books/NBK525997/ .

McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease

in adults and children (8th ed.). Elsevier.

The Centers for Disease Control and Prevention. (2018, 1st November). Pharyngitis

(Strep Throat): Information For Clinicians. Centers for Disease Control and Prevention.

https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html