Running head: EPISODIC NOTE 1
EPISODIC NOTE 3
Focused SOAP for a patient with throat pain
CC: Throat pain
HPI: the patient is thirteen years old male who developed sudden onset of pain while swallowing which began yesterday. The pain is described as “really bad sore throat” and is rated two out of four. The pain gets worse with swallowing. The patient reports feeling very tired. Tonsil stones are located on the right side and there is presence of white patches on his tongue. The patient tried Motrin with minimal relief of his symptoms.
Current Medications: children’s Motrin
Allergies: food-none, environmental-none, PCN-rash
PMHx: covid-19 vaccine on 22/23/2021
Soc Hx: Negative for tobacco use currently or previously, likes swimming, stable family status
Fam Hx: No history of asthma in first degree relatives. Father is a smoker
· General- positive for fever, tiredness and chills. Denies weight loss
· Head: reports onset of headaches, blurred vision and drainage
· EENT-reports a sore throat, cough and difficulty while swallowing, denies running or congested nose, denies double vision, reports no ear pain
· Skin-presence of skin rash
· Pulmonary- positive for cough
· Gastrointestinal- positive for nausea without vomiting, negative for diarrhea, abdominal pains, reports loss of appetite
· Respiratory- denies shortness of breath, cough or sputum. Reports intermittent cough
Gastrointestinal: There is no distention in the belly, and bowel movements are in all locations.
Pulmonary: Both lungs are open to percussion.
CDC influenza SARS-Cov-19 multiple assay- to distinguish covid-19 from influenza virus (Ovchinnikov et al., 2020)
WBC with differential shows an elevation (14000cubic millimeters)- to confirm infection (Karam et al., 2019) .
Bacterial pharyngitis- this due to the presence of cough, pain while swallowing and fever.
Covid-19- due to the presence of fever and cough
Croup- due to coughing, fever, tiredness and sore throat (Karam et al., 2019)
Measles- due to the skin rash, sore throat and fever
Common cold- due to the presence of fever, throat irritation and cough
The physical diagnostics will using a lit device to examine the throat and possibly enlarged glands. Include using a lit device to examine the throat and possibly enlarged glands (Prescott et al., 2019). The results will be used to rule out other diseases to arrive at the main illness.
Karam, M., Victor, R., & Singh, H. (2019). Fungal Infections in Ear, Nose and Throat: A Clinical Study. Annals Of International Medical And Dental Research, 4(3).
Ovchinnikov, A., Miroshnichenko, N., & Nikolaeva, Y. (2020). Sore throat. Recent trends in treatment. Vestnik Otorinolaringologii, 85(4), 35.
Prescott, K., Mahida, N., & Boswell, T. (2019). Healthcare worker screening in Streptococcus pyogenes outbreaks using throat and perineal swabs. Journal Of Hospital Infection, 101(4), 485-486.
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