Focused Episodic Soap Note for Sore Throat

1 Focused Episodic SOAP Note for Sore Throat Patient: LG Age: 20 Sex: Female Race: African American S HPI: A 20-year-old African American female presented to this clinic with a chief complaint stat “ I have had a cough and sore throat for the last three days.” Reports intermittent cough, dysphagia, rhinorrhea, and feeling tired and achy all over. Describes cough as intermittent, nonproductive, and without pain. Sore throat produces painful swallowing rated as 5/10 (Pain Rating Scale). Overall body achy reported as dispersed at 5/10 on the same rating scale. She denies congestion. LG manages current illnesses with increased fluids, OTC medications that bring temporary relief. Reports resting in bed most of the days. For the last three days she has not attended class and plans to call out from work if problems do not resolve by the weekend. Current Medications: 1. Tylenol 500mg tablets by mouth every 6 hours PRN pain (Throat pain and body ache) 2. Luden’s Dual Relief Cough Drops, 2 drops every 4 hours PRN to sooth throat and suppress cough 3. Ortho-Novum 1/35-28 tablets, 1 tablet daily for 28 day to begin at start of menstrual cycle (Birth control) 2 Allergies/Immunization: 1. NKDA 2. NKFA 3. Denies environmental allergies to dust, pollen, dirt, dairy, and latex products 4. Received all scheduled childhood immunizations and boosters for college 5. Denies ever receiving the influenza vaccine PMH: Reports UTD on all childhood immunizations. Last tetanus shot six-months ago. Reports having chickenpox at 11-years of age. Reports attempts to make healthy food selections and avoiding most fried foods and red meats. Denies surgical history. FH: 1. Lily is an only child with no known medical problems. 2. Mom, age 60 and living. History of HTN and Asthma, diagnosed in her early twenties. 3. Dad, age 65 and living. History of HTN, Hyperlipidemia, Diabetes (Type 1) diagnosed in his late thirties. 4. Both parents were adopted at birth. No known maternal or paternal history available. SH: Lily is a single full-time student at Walden College. She works 16-hours every weekend at the campus BABA, as a housekeeper cleaning grills, bathrooms, and taking out trash. LGs exposed to irritating cleaning fluids and aerosols at work. She brings home about $225 a week. Weekday meals are usually consumed at the campus’s cafeteria with close friends. Friday evenings she participates in a study group in one of the campus dorms with friends. She denies recreational drug use (cigarettes, vapes, cigars, and pipes). Reports s intentionally avoid others who smoke or drink alcohol. Denies use of illegal drugs (marijuana, cocaine, and ecstasy) stated, 3 “I really want to focus on my studies to become a Nurse Practitioner., those things would just get in my way.” Denies use of alcohol. Engages in a heterosexual relation with one male partner for the last year, stated, “John is my first and only experience.” Currently taking oral birth control, uses condoms, and avoids oral or anal intercourse. Reports Catholicism as her religion but denies devoutness in attendance and practices. Reports valid driver’s license, parks vehicle on campus grounds and drives to and from work. Reports use of seatbelts on every drive. Denies using cell phone or texting while driving. ROS: General – Reports low grade fevers over last 3-days (100.0F-102.0F), chills, malaise, and exhaustion. Reports possible loss in weight due to loss of appetite. Head – Reports onset of headaches, blurred, double vision, or drainage. EENT – Reports no ear pain, no drainage, no vertigo, tinnitus, or loss in sound. Reports rhinitis with clear drainage, and no nasal pressure. Reports non-productive cough, sore throat with difficulty swallowing. Integumentary – Reports skin warm to touch, free from rashes, dryness, or lesions. Cardiovascular – Reports chest tenderness following coughing episode. Denies palpitations and peripheral edema. Respiratory – Reports intermittent cough. Denies presence of phlegm or shortness of breath. Gastrointestinal – Reports loss of appetite. Denies n/v, diarrhea, constipation, abdominal pain, or tenderness. Genitourinary – Denies pain on urination, hematuria, pregnancy, STD. Recalls date of last period ended three days ago. 4 Neurological – Reports no headache, numbness, prickling, or syncope. Musculoskeletal – Reports generalized achiness in soft tissues and joints of extremities. Hematologic/Lymph – No bruises or bleeding. Reports increase in size of glands in neck. Psychiatric – No diagnosed hx of depression, suicide, or mood disorders. Endocrine – Reports increase in body temperature at night over las 3-days with temp. ranging from 99.8F to 100.0F. Denies polydipsia, polyuria, incontinence, and dysuria. Allergies – NKDA, NKFA, with no environmental or latex adverse reactions. O: VS: T-100.0F, P- 98, R- 22, B/P: 120/72, Pox: 97%RA, HGT: 5.5, WGT: 135lbs., BMI: 22.5 General: LG presents AAO x 3 to person, place, and time. She is appropriately dressed and malodorous. LG observed with a runny nose and hand full of used tissues. Arms crossed at trunk and rocks back and forth. Audible hoarseness with speaking and coughing. Well articulate and good historian of information. Negative for signs of respiratory distress. HEENT: Head: normocephalic. Eyes: Red, watery, with PERRLA. Ears: normal shape and size and no drainage. Nose: patent with clear exudate, and non-deviated septum. Throat: mucous membranes dry, no ulcerations, good dentition, and no cavities. Neck: soft with positive adenopathy on palpation. Cardiovascular: RRR, and negative signs of cyanosis, murmurs, or edema. Respiratory: Trachea midline, bilateral equal expansion of chest wall, with observed tachypnea. No masses, bulging or crepitus felt on palpation. Fine crackles, with inspiratory wheezing heard on auscultation and no stridor. 5 A: DIAGNOSTICS: 1. CBC – establishes a baseline for future comparisons and to detect increase or decrease in blood cell count (Moores, 2018 update) and (Dains & Scheibel, 2019) 2. WBC with differential shows an elevation 15,000 cubic millimeters) – to confirm infection 3. CDC Influenza SARS-CoV-2 (Flu SC2) Multiplex Assay – to distinguish COVID-19 from Seasonal Influenza) (CDC, 2020) Differential Diagnosis: 1. Influenza virus (bacterial or viral) – Flu season in the United States, most active from December through February (CDC, 2018) 2. Corona virus – Current pandemic (CDC, 2020) 3. Asthma – Family history (Ball et al., 2019) 4. Acute Bronchitis – Prolonged breath sounds, crackles, and wheezing (Ball, et al., 2019) 5. Hypersensitivity pneumonitis – Exposure to some environmental substances can trigger an immune response resulting in lung inflammation (NHLBI, ). LG’s exposed to cleaning products. P: 1. Encourage increased clear fluid intake, rest, soft diet as tolerated, and good hand hygiene 2. Educate on patient on signs of distress and when she needs to report to the hospital 6 Client Problem: The common cough and sore throat signifies symptoms of a cause. Causes associated with coughs may develop in response to exposures to irritants, inflammation, underlying pulmonary matters or even suggest a state of anxiety (Ball et al., 2019). When an influenza outbreak occurs in community setting, practitioners may not order diagnostic testing. Diagnosing the flu may occur in conjunction with patient presentation of signs and symptoms and what is taking place in the community at the time (CDC, 2016). Nurses know that several diseases share common signs and symptoms (i.e., influenza and corona virus), but focused history and physical assessment can develop potential differential diagnoses and rule out others. If additional laboratory and diagnostic tests are required, then practitioners must offer appropriate documentation of the history and physical examination that supports ordered tests (Sullivan, 2019). Some clinicians may encourage fluids and dietary changes along with medication to treat associated symptoms knowing the flu can resolve without treatment. However, the recent Corona virus pandemic has encouraged practitioners to order RIDT testing to distinguish influenza A or B from the Corona virus (CDC, 2020). In all cases, patients should receive education and instructions on follow-up visits and how to recognize and respond to the very signs and symptoms that could lead respiratory destress.