SOAP Note Week Two
United States University
FNP592: Common Illnesses Across the Lifespan
Dr. Theresa Gress
October 1, 2020
SOAP Note Week Three
ID: Mickey Mouse, DOB 1/1/2000, age 20, white Hispanic male presents to the clinic unaccompanied and appears to be a reliable historian.
S:
CC: “Cough, runny nose, and sore throat x 7 days”
HPI: New Asian male patient 28 yo presents to the clinic unaccompanied, complaining of non-productive cough, runny nose and sore throat x 7 days (1/7/2020). Currently somewhat controlling symptoms with Dayquil and Nyquil. Cough mild, worsened when laying flat. Highest temp at home 99 degrees. Patient wondering if he needs antibiotics. Rates pain in throat as 4/10, described as “aching, swallowing makes it worse”, relieved by Dayquil/nyquil. Denies headache, denies sick contacts or recent travel. Denies feeling worse outdoors or seasonally. He is a reliable historian
PMH:
Allergies: No known drug allergies. Strawberries (rash), seasonal allergies
Childhood: Asthma until high school, chickenpox at age 2
Surgical: Tonsillectomy (1998), Wisdom Teeth Removal (2005)
Medications: None
Vaccinations: received childhood vaccines, Last flu shot given Oct 2019.
Denies psychiatric history.
Social History:
Denies tobacco/e-cigarette use. Admits to occasional once every 2-3 months alcohol use – last drink
2 months ago, Engaged, works in IT, Hobbies include archery.
Family History:
Mother died age 60-Diabetes II
Sister 42yo living -HTN
Maternal Grandma died age 67- Dementia
ROS:
General: No weight change, weakness, fatigue, fevers..
Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred vision, or blindness.
EarsNose/Throat/mouth: no hearing change, tinnitus, earaches, infection, discharge. POSITIVE FOR RHINORRHEA. No sinus pain or epistaxis. POSITIVE FOR SORE THROAT, HOARSE VOICE. No bleeding gums, dentures, sore tongue, dry mouth. Last dental exam was 4 months ago.
C/V: Denies chest pain, palpitations.
Pulmonary: POSITIVE FOR NON-PRODUCTIVE COUGH, negative hemoptysis, dyspnea, wheezing, pleuritic pain
Neuro: No headache, dizziness, focal numbness/weakness, nausea, vomiting.
Lymph: Denies swollen lymph nodes in neck.
Allergy/immunology: Denies seasonal allergies or allergy to pets, pollen or other. Denies frequent illness.
O:
VS: T – 98 P – 80 R – 16 BP – 128/72 O2 sat – 99% – 4/10 pain in throat. Wt: 205 Ht: 72 in BMI: 27.8
Skin: Natural in color, warm, smooth and dry. Good skin turgor, no lesions, rashes, ecchymosis or moles. Nails without clubbing or cyanosis.
HEENT:
Ears: pinna clean, no exudate noted. TM intact and pearly gray with cone of light bilat.
Nose: nasal mucosa pink and moist. Inferior turbinates slightly reddened bilat. Nares patent bilat. No sinus pain upon palpation. Septum midline.
Throat: oral mucosa pink and moist, tongue mobile without lesions, tonsils absent. Posterior pharynx with erythema but no cobblestone appearance.
Neck: non-tender cervical area, no lymph nodes palpable. Non-enlarged thyroid palpated. Trachea midline.
Neuro: Alert and oriented x 4.
Cardio: RRR. Crisp S1 S2 without clicks or murmurs.
Thorax and lungs: Thorax is symmetric with good expansion. Respirations are even and unlabored. No use of accessory muscles, stridor, grunting, or nasal flaring. Lungs CTA Bilaterally.
(***notice not all systems are in the PE when doing a focused exam on a problem)
A:
Differential DDX: INCLUDE AT LEAST 3 DIFFERENTIALS
- Viral pharyngitis – most likely as evidenced by sore throat, cough, no fever (Stead, 2019). (←←←←←that is a practice treatment guideline)
- Strep Throat – not as likely; no fever and 7 days duration, age not as consistent with this dx
- Allergic rhinitis – no report of sx increasing with outdoor activity or exposure to allergens, sx with sore throat are less likely for allergies.
DX: Viral pharyngitis
P:
In house throat swab for rapid strep – negative.
Continue to rest and drink lots of fluids (Cash & Glass, 2017; Stead, 2019).
Continue OTC Dayquil/Nyquil PRN per directions on the box – Safe dosing discussed, sedation may occur with Nyquil, avoid driving or operating heavy machinery after taking.
Encourage tea with honey and lemon to help with cough and sore throat.
Gargle with warm salt water 2-3 times a day for 30 sec, swish and spit.
Do not drink alcohol while taking these medications.
Cover mouth when coughing, do not drink after other people (Cash & Glass, 2017).
Return to office in 3-4 days if symptoms do not improve, worsen, or get better and then again get worse (Cash & Glass, 2017).
Call 911 or go to ER for trouble breathing or any other emergent concern (Stead, 2019).
References:
Cash, J. & Glass, C. (2017). Family practice guidelines. New York, NY. Springer.
Stead, W. (2019). Symptomatic treatment of acute pharyngitis in adults. In L. Kunnis
(Ed.). UpToDate Retrieved February 12, 2020 from:
https://www.uptodate.com/contents/symptomatic-treatment-of-acute-pharyngitis-
in-adults