Episodic-Focused SOAP Note Template-Painful Swallowing and Sore Throat 13-Year-Old Male
Patient Information:
Name: Jason
Age: 13 years
Gender: Male
S.
CC “Painful swallowing and sore throat.”
HPI: Jason is a 13-year-old male who presents with complaints of painful swallowing and a sore throat. According to the patient, the symptoms started yesterday and have persisted. They were initially described as a “really bad sore throat.” Jason describes the pain as a sore throat aggravated by swallowing. Associated signs and symptoms include general body weakness, fever, and painful swallowing. The symptoms are especially worse during nighttime. There are no specific exacerbating factors. However, his mother administered over-the-counter Children’s Motrin, which helped to reduce his fever but did not alleviate the sore throat. The patient did not quantify the severity of the pain.
Current Medications: Children’s Motrin (OTC): Dosage: Follows the recommended pediatric dosage. Frequency: As needed. Length of Time Used: Started recently. Reason for Use: To alleviate fever symptoms
Allergies: No known medication, food, environmental allergies, or adverse reactions were reported.
PMHx: There is no history of chronic illnesses, surgeries, or admissions. The patient is currently receiving all age-appropriate immunizations, including the last tetanus vaccination received two years ago.
Soc Hx: The patient is currently a student and has no occupation outside their studies. He enjoys playing soccer and participating in a local child club. There is no history of alcohol or tobacco abuse. The patient lives with their mother and younger sibling. They have a supportive and stable family environment. The patient resides in a suburban area with their family. They have a safe and comfortable living environment with access to necessary amenities.
Fam Hx: His parents are alive and healthy, without any reported chronic illnesses. He has one younger sibling who is in good health and has no known chronic illnesses. His grandparents are all alive and in good health.
ROS:
GENERAL: The patient denies fever, weight loss, fatigue, or chills.
HEAD: No reported headaches, head trauma, or dizziness.
EENT (Eyes, Ears, Nose, Throat):
Eyes: No visual loss, blurred vision, or double vision.
Ears: No hearing loss or ear pain.
Nose: No sneezing, congestion, or runny nose.
Throat: Reports sore throat and painful swallowing.
SKIN: No rash or itching reported.
CARDIOVASCULAR: Denies edema, palpitations, or chest pain.
RESPIRATORY: Denies cough or dyspnea.
GASTROINTESTINAL: No reported nausea, abdominal pain, diarrhea, or vomiting.
GENITOURINARY: Denies dysuria, hematuria, increased frequency or urgency
NEUROLOGICAL: No reported headaches, syncope, or dizziness
MUSCULOSKELETAL: Denies muscle or joint pain, joint stiffness, or back pain.
HEMATOLOGIC: No reported easy bruising, or bleeding
LYMPHATICS: No reported lymphadenopathy
PSYCHIATRIC: No anxiety or depression was mentioned.
ENDOCRINOLOGIC: No reported cold or heat intolerance, sweating, polydipsia, or polyuria.
ALLERGIES: Denies hives, asthma, or allergic rhinitis.
O.
Physical exam:
General: The patient appears to be a 13-year-old male in no acute distress. He is alert, cooperative, and appropriately oriented to person, place, and time. There are no visible signs of discomfort or abnormal behavior.
Head: Normocephalic and atraumatic. No palpable tenderness or deformities were noted.
Eyes: Pupils are equal, round, and reactive to light. Conjunctiva is clear. No scleral icterus or discharge was observed. Extraocular movements are intact. No ptosis or nystagmus was noted.
Ears: Bilateral external ears are symmetrical without swelling or discharge. Tympanic membranes are pearly grey and intact bilaterally. No tenderness or erythema was observed.
Note: No external deformities or tenderness. Nasal passages are patent. No discharge or polyps were noted.
Throat and Oropharynx: Tonsils are enlarged (2+) and erythematous. Tonsil stones are present on the right side. White patches are visible on the tongue. No uvular deviation or exudate was observed. No cervical lymphadenopathy is appreciated.
Neck: Supple. No palpable lymphadenopathy. No thyromegaly or thyroid nodules were detected. No jugular vein distention was observed.
Respiratory: Chest expansion is symmetric. Respiratory effort is normal. Clear breath sounds bilateral. No wheezing, crackles, or rhonchi are appreciated.
Cardiovascular: Regular rate and rhythm. No murmurs, gallops, or rubs. Peripheral pulses are equal and symmetric. No edema was observed.
Abdomen: Soft and non-tender to palpation. No hepatosplenomegaly or masses appreciated. Bowel sounds are present in all quadrants.
Genitourinary: External genitalia appears normal for age. No swelling, discharge, or lesions were observed.
Musculoskeletal: No deformities, swelling, or joint tenderness noted. Full range of motion observed in major joints.
Neurological: Alert and oriented. Cranial nerves II-XII intact. No focal motor or sensory deficits are appreciated. Coordination and gait are normal.
Skin: No rashes, lesions, or abnormal pigmentation observed. Skin is warm and dry.
Diagnostic results:
Throat Culture: To identify the causative organism responsible for the patient’s symptoms (Ball et al., 2019)
Complete Blood Count (CBC): To assess the patient’s overall blood cell counts and detect abnormalities (Ball et al., 2019).
Rapid Streptococcal Antigen Test: To determine the presence of Streptococcus bacteria as a potential cause of the patient’s symptoms (Anderson & Paterek, 2022).
Monospot Test: The mono-spot test was performed to check for antibodies associated with infectious mononucleosis (Sullivan, 2019).
Soft tissue lateral nasopharynx X-ray: will reveal the size of adenoids and the extent to which nasopharyngeal air space has been compromised (Anderson & Paterek, 2022).
Diagnostic nasal endoscopy: Examination of postnasal space: adenoid mass can be seen with a mirror; a rigid nasopharyngoscope is also helpful to see details of the nasopharynx (Sullivan, 2019).
Chest X-ray: A chest X-ray is used to evaluate the patient’s respiratory system and rule out any pulmonary involvement (Sullivan, 2019).
A.
Differential Diagnoses:
Acute Tonsillitis: Inflammation and infection of the tonsils can lead to symptoms such as sore throat, difficulty swallowing, and swollen tonsils. The presence of enlarged and erythematous tonsils with tonsil stones supports the possibility of tonsillitis. Diagnosis is based on clinical examination findings and may be confirmed by throat culture or rapid streptococcal antigen test (Anderson & Paterek, 2022).
Streptococcal pharyngitis: This is a common bacterial infection caused by group A Streptococcus bacteria. A throat culture is considered the gold standard for diagnosing streptococcal pharyngitis, especially when the clinical presentation is consistent with the infection (Sykes et al., 2020).
Infectious mononucleosis: It is caused by the Epstein-Barr virus (EBV) and can present with symptoms including sore throat, fatigue, and swollen lymph nodes (Wu et al., 2020).
Oral candidiasis: White patches on the tongue suggest the possibility of oral thrush, a fungal infection caused by Candida species. It commonly occurs in individuals with weakened immune systems or those treated with antibiotics. Diagnosis is usually based on clinical examination; fungal culture or microscopic examination can provide confirmatory evidence (Anderson & Paterek, 2022).
Viral pharyngitis: Viral infections, such as those caused by adenovirus or influenza, can present with sore throat symptoms, fatigue, and malaise (Sykes et al., 2020). Diagnosis is clinical, and supportive care is often the mainstay of treatment.
Primary Diagnosis/Presumptive Diagnosis:
Acute tonsillitis. This diagnosis is supported by the patient’s symptoms of painful swallowing, tiredness, and enlarged and erythematous tonsils with tonsil stones on the right side. The white patches on the tongue could also be attributed to the inflammation and infection of the tonsils (Anderson & Paterek, 2022).
This section is optional for the assignments in this course (NURS 6512) but will be required for future courses.
References
Anderson, J., & Paterek, E. (2022). Tonsillitis. In StatPearls [Internet]. StatPearls Publishing.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
Sykes, E. A., Wu, V., Beyea, M. M., Simpson, M. T., & Beyea, J. A. (2020). Pharyngitis: approach to diagnosis and treatment. Canadian Family Physician, 66(4), 251-257.
Wu, Y., Ma, S., Zhang, L., Zu, D., Gu, F., Ding, X., & Zhang, L. (2020). Clinical manifestations and laboratory results of 61 children with infectious mononucleosis. Journal of International Medical Research, 48(10), 0300060520924550. DOI: 10.1177/0300060520924550