SOAP NOTE

Name: N.C

Date: 10/26/2020

Time: 09.30 h

Age: 5-year-old

Sex: M

CC: “I have sore throat”

HPI: 

A 5 y/o Hispanic male presents to the clinic complaining of sore throat that started 3 days ago. Describes that occasionally feels like “piercing or burning” pain that it is constant. Also, that is very painful to swallow. Mother states patient developed cold symptoms (cough, sneezing) about 5 days ago, sore throat started 3 days ago, and fever of 101.5 F began 24h ago. Patient added that the pain varies in intensity, rated anywhere from 8 to 9 on a Wong-Baker scale when eating or drinking, but at this moment rated his pain at 5. Reports that pain is not radiating to any surrounded area and “is better when drinking sips of a cold liquids like water or Kool-Aid or takes Ice cream”. Mother also states that fever somehow is relieved by rest and Tylenol. Confirms that his appetite has decreased in the last 3 days.

Medications: 

Tylenol OTC PO PRN

PMH 

Allergies: NKDA

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None

Immunizations: 

– According to CDC for his age group, he is up to date with the following vaccines

•          Influenza 2019

•          Tdap 5th dose

•          MMR 2nd dose

•          Polio IVP 4th dose

•          Chickenpox (Varicella) 2nd dose

Family History:

Mother: Alive – no significant medical history

Father: Alive – HTN

Sister: 8 years old healthy

Brother: 2 days old healthy

Social History

Lives with both parents and siblings. Appears comfortable and happy with mother in the room. Neither parents smoke. Patient began kindergarten this year at local public school.

General 

Patient reports sore throat, but overall healthy, appropriate weight and height for age, usually very active but mostly lying around the past few days per mom.

Cardiovascular

Denies chest pain or palpitations.

Skin

Denies rash, inflammation, pain, tenderness, or skin lesion.

Respiratory

Denies any cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB exposure or symptoms per mom, or SOB.

Eyes

Denies use of corrective lenses or glasses, blurred vision, or visual changes of any kind.

ENT

Denies ear pain, hearing loss, ringing in ears, discharge. Reports no sinus problems, or nose bleeding. Complains of sore throat and aggravating pain when swallowing. Goes to dentist every 6 months per mom.

Gastrointestinal

Denies diarrhea, abdominal pain, or heartburn. He had his last bowel movement this morning and goes at least once a day.

Genitourinary

Denies urgency, frequency or burning and pain with urination. Reports no hematuria or change in color of urine. Denies penile pain.

Musculoskeletal

Denies back pain, joint swelling, stiffness, or muscle pain.

Heme/Lymph/Endo 

Denies fatigue. Mother states swollen/tender cervical lymph nodes. Patient is appropriate size and weight for his age.

Neurological

Denies any syncope, seizures, transient paralysis, paresthesia or black out spells per mom.

Psychiatric

Denies any nightmares; patient seems happy and answers questions appropriately when asked directly.

OBJECTIVE – 

Weight  47.6 lbs.    BMI 15.1          Temp 100.1F  BP 103/67

Height 47”     Pulse 108       Resp 18

General Appearance

Happy. Alert and oriented in all spheres; answers questions appropriately when asked directly, but otherwise shy. Cooperative.

Skin

Skin is warm, dry, no rashes or lesion noted.

HEENT

Head is normocephalic, atraumatic and without lesions. EYES: Extra ocular muscles intact, PERRLA. Ears: TM’s shiny, EAC clear, hearing intact, mild tympanic membrane bulging. Nose: Bilateral turbs red and swollen, septum midline. Throat: Posterior pharyngeal erythema, white pus pockets noted on swollen tonsils.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs.

Respiratory

Symmetric chest wall. Respirations regular and unlabored; lungs clear to auscultation in all fields bilaterally.

Gastrointestinal

Abdomen is flat, BS normoactive in all 4 quadrants. No hepatosplenomegaly, soft no tender on palpation. Bowel sound normoactive in all 4 quadrants.

Lymphatic

Swollen cervical nodes bilaterally, tenderness on palpation.

Genitourinary

Bladder is non-distended, non-tender. External genitalia normal, no lesions observed. Tanner Stage 1.

Musculoskeletal

Full ROM seen in all 4 extremities without any difficulties.

Neurological 

Speech clear. Good tone. Posture is erect, balance stable and gait is normal.

Psychiatric

Alert and oriented. Maintains good eye contact. Speech is soft, and clear and of normal rate and cadence for age. Answers questions appropriately when asked directly, otherwise shy. Displays no mood disorders.

Lab Tests

CBC, CMP: pending

Special Tests

Strep Swab: Positive

Culture and sensitivity of tonsils exudate: pending

Primary Diagnosis

•          J02.0 Streptococcal Pharyngitis: Common signs and symptoms of streptococcal pharyngitis include sore throat, temperature greater than 100.4°F (38°C), tonsillar exudates, and cervical adenopathy. Cervical node lymphadenopathy and pharyngeal or tonsillar inflammation or exudates are common signs. Palatal petechiae and scarlatiniform rash are highly specific but uncommon; a swollen uvula is sometimes noted. Available diagnostic tests include throat culture and rapid antigen detection testing. Throat culture is considered the diagnostic standard, although the sensitivity and specificity of rapid antigen detection testing have improved significantly.

Differential Diagnoses: 

•          J03.90 Acute Tonsillitis: Tonsillitis is most often a viral infection caused by cold viruses and starts suddenly and lasts for a week or two. Patients with tonsillitis typically present with a sore throat, swollen tonsils that are erythematous, and have a yellowish coating, difficulty swallowing, fatigue, fever, and loss of appetite (IQWiG, 2019). The patient in this case study does not have any coating of the tongue, loss of appetite, or fatigue noted so this is not likely to be the primary diagnosis.

•          B27.9 Infectious mononucleosis: Mononucleosis is caused by the Epstein Barr Virus and it is common to have inflammation of the tonsils with exudates which can also present with a generalized abdominal pain (Ruppert, 2015). This patient is middle aged and therefore, it is less likely that this is the diagnosis as it is not commonly seen in adults, but rather in adolescent to young adults between 15 to 24 years old. There is a test for mononucleosis called the Monospot test; however, it takes several weeks for a positive result to appear. This often tends to be inconvenient and often it is treated based on symptoms alone (Lyden, 2017). This is not likely to be the diagnosis for this patient as patients with mononucleosis have severe malaise and fatigue, which this patient has not reported.

•          D24.1 Acute pharyngitis: Pharyngitis is caused by inflammation to the pharynx and can occur in both adults and children and is due to either infection or irritation (Lyden, 2017). This is a very common condition and can be either viral or bacterial in nature. Bacterial pharyngitis is most commonly a result of a group A strep infection and according to Lyden (2017), it presents with erythema of the tonsils or throat, exudate which can be discrete or patchy, white or yellow, pharyngeal petechiae, and tenderness in the anterior cervical adenopathy. Viral pharyngitis is almost always caused by the rhinovirus and presents with cough, mild erythema, nasal drainage or stuffiness, fever, but no tenderness or lymphadenopathy (Lyden, 2017). This patient most likely has bacterial pharyngitis as the neck is tender with enlarged anterior cervical lymph nodes.

Plan/Therapeutics/Referrals/Education

Plan: 

1.        Children’s Motrin Oral suspension q8h PRN for pain and fever

2.        Amoxicillin 400/5ml Oral suspension for 10 days

3.        Advised to follow-up in 1 week to ensure medication course was followed and was effective.

4.        Results of all tests to be reviewed with patient in 1-week follow-up appointment.

Referrals:

No referral currently.

Patient Education:

–          Stop Tylenol and start with the prescribed NSAID.

–          Take the prescribed antibiotics for full treatment even if symptoms seem better in a few days. Do not stop earlier.

–          Increase cold fluid intake.

–          Saltwater gargles at least 3 times daily.

–          Rest, and no school until fever free for 24 hours.

–          If symptoms worsen direct yourself to the nearest ER.

References

Institute for Quality and Efficiency in Health Care (IQWiG) (January 17, 2019). Tonsillitis: Overview. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK401249/

Lyden, E. A. (2017). Chapter 101: Pharyngitis and Tonsillitis. In T. Buttaro, J. Trybulski, P. Polgar-Bailey, & J. Sandberg-Cook (Eds.), Primary care: A collaborative practice (5th ed., pp. 413-416). St. Louis, MO: Elsevier