Discuss diagnosis and treatment of Sore Throat

Week 4 SOAP Note

United States University

Advanced Health and Physical Assessment Across the Lifespan MSN 572

Shannon Ripley

03/27/2021

SOAP

SUBJECTIVE:

ID: William Henry Ripley Jr, DOB 10/06/1950, age 70, white Caucasian male came to the clinic

alone for complaints of a “sore throat”. Bill is married to his wife for 42 years and lives in a

home independently. He works for the forest service and BLM. Patient appears to be a good

historian of his medical history and can answer all appropriate questions.

CC: “sore throat”

HISTORY OF PRESENT ILLNESS (HPI): Bill 70 year old male, Caucasian, came in for a “sore

throat”. Bill began to feel a sore throat a week ago with pain 3/10, it has increasingly gotten

worse to a sharp pain that is 7/10, he states it feels like he is swallowing glass. Bill has not been

eating solid food but has been drinking shakes for the last 2 days due to difficulty and pain while

swallowing. He states that drinking tea with lemon and honey or gargling salt water has helped

slightly, he also diffuses essential oils while he sleeps. Bill spiked a fever of 102 degrees

Fahrenheit last night, he took Tylenol 1000mg, PO x1 dose which decreased the fever to 98.6F.

Bill is not coughing, sneezing or have any nasal congestion. Bill does not have any seasonal

allergies and has not been around irritants such as smoke, pollen, molds, animal dander, or

indoor inhalants such as hair spray or aerosol products. He was recently at a birthday party and

around a friend who had a sore throat and later tested positive for streptococci group A. Bill

started feeling symptoms shortly after the birthday party and came in to get tested today. Last

physical was 12/2020. No recent immunization, denies getting the flu, pneumonia, shingles or

COVID vaccine. Last dental exam 11/2020. Denies any use of medications.

PAST MEDICAL HISTORY:

Tinnitus

Childhood illness: Patient had pneumonia as a young child (date unknown) and colon bacillus in

1965.

Chronic illness: Patient denies chronic illnesses.

Psychiatric history: patient denies psychiatric illnesses

PAST MEDICAL PROCEDURES:

Procedures: Tonsillectomy in 1958, laminectomy in 1970, removal of non-Hodgkin lymphoma

tumor in 07/1998, TURP in 11/2003, staple removal from chest in 8/2014 and fall of 2017. See’s

the dermatologist every 6 months to get pre-cancerous cells burned off.

Hospitalized: tumor removal in 07/1998 and during the laminectomy in 1970. No reactions to

anesthesia.

Last dental checkup 11/2020

MEDICATIONS:

Tylenol 1000mg, PO tabs, TID, as needed.

Daily vitamin, vitamin b12 complex BID, joint vitamins (does not remember name) and herbal

supplements. Uses the chiropractor and physical therapy as alternative health care practices.

ALLERGIES:

Denies allergy to medications, latex, environmental factors or food.

LMP (as applies)

Not applicable

FAMILY HISTORY:

MGM: Died in 1948 of hemophilia

MGF: Died in 2002 of melanoma

PGM: Died in 1968 of cancer of the digestive tract

PGF: Died in 1962 of emphysema

Father: Died in 1979 of liver cancer, type 2 diabetes

Mother: Died 2015, had diabetes type 2, overweight, and Alzheimer’s

Aunts: Type 2 diabetes, Alzheimer’s

Uncles: none

Siblings: none

Children: none

Bill denies that anyone in his family is experiencing any head, ear, eye, nose, or throat problems

at this time. Bill denies any family history of fever, chills, or allergies.

SOCIAL HISTORY

Sexual/Reproductive: Denies any STI’s, has one partner.

Tobacco/Vaping: Denies any tobacco or vaping use of any kind

Alcohol use: Drinks 3oz of wine per week

Drug use: Denies any drug use

Marital history: Married to his wife for 42 years who is his only partner.

Occupation: Forest Service

Exercise/Diet: Diet is high in organic fruits, vegetables, meats, whole wheat bread, smoothies,

and seeds. Eats moderate amounts of salt. Rarely eats out. Drinks small amounts of caffeine.

Exercises 4x per week swimming and weight lifting. Hobbies consist of camping, spending time

with family and traveling. Alternative health care practices include chiropractor and physical

therapy.

Sleep/Stress: 7.5 hours per night, goes through periods of sleeping large and small amounts.

Patient feels rested with the sleep he gets.

Immunizations

Immunization Total Doses Up-to-date?

Hepatitis B 3 doses Yes

Diphtheria, Tetanus, and Pertussis (DTap)

5 doses Yes

Polio 4 doses Yes

H. influenza type B 4 doses Yes

Pneumococcal conjugate 4 doses Yes

Oral Rotavirus 2 doses Yes

Measles, Mumps, Rubella (MMR)

2 doses Yes

Varicella 2 doses Yes

Hepatitis A 2 doses Yes

Influenza Annually No

COVID Pfizer 2 doses No

Tdap 1 dose Yes

Meningococcal conjugate at 2 doses Yes

Human Papilloma Virus (HPV)

2 doses Yes

Spiritual affiliation: Christian

Safety: denies any domestic abuse or violence. Wears helmets while riding a bike and seat belt

while driving. Denies any pool on property or safety hazards. Denies owning guns.

REVIEW OF SYSTEMS:

Constitutional: Patient had fever of 102F last night with chills and increased fatigue. Denies any

unintentional weight loss.

Eyes: denies changes of vision, blurred vision, floaters. Last eye exam: 2018

Ears, Nose, Throat: Patient experiencing a sore throat with difficulty swallowing due to pain

and swelling. Patient complaining of swollen tonsils with white patches with a bright red throat.

Denies a runny nose or any discharge. Patient has chronic tinnitus but denies any further changes

or difficulty in hearing, ear pain or discharge. Denies change or difficulty smelling.

Cardiovascular: Denies chest pain, abnormal heart beats, skipping beats, fluttering, shortness

of breath with/without exertion

Respiratory: Denies difficulty breathing or coughing.

Gastrointestinal: Has 2 bowel movements per day, soft consistency and small quantity due to

not being able to eat large amounts at a time. Denies any blood in stool, diarrhea or constipation.

Genitourinary: denies pain with urination, denies abnormal vaginal discharge, denies urinary

urgency or frequency.

Musculoskeletal: denies joint pain, reports full ROM in upper and lower bilateral extremities.

left shoulder healed well from surgery, no concerns per patient.

Integumentary/Breast: denies rashes, skin dryness, lesions or nodules.

Neurologic: Denies any dizziness, blurred vision, unsteady gait, unilateral weakness, peripheral

neuropathy symptoms or seizures.

Psych: Denies feeling down, depressed or hopeless.

Endocrine: Denies unintentional weight loss, heat or cold intolerances or excessive sweating.

Hematologic/Lymphatic: Bill does complain of enlarged lymph nodes in neck. Denies getting

sick frequently. Denies bruising easily, prolonged bleeding, taking a long time to heal.

Allergic/Immunologic: Denies allergy to any foods or environmental substances. Denies

allergies to any medications.

Objective

Physical Exam: Vital Signs BP: 110/80

HR: 100 Resp: 16 O2: 97% on room air

Temp: 99.4 Oral

Pain: 7/10

Height 6ft 2in. Weight: 140. BMI: 18

Physical

GENERAL survey: Patient looks fatigued and in pain. He is breathing with ease and looks well

hydrated and fed. Hygiene is clean with no odors. Patient walked into the office independently

and drove self. Patient is attentive and answers all questions thoroughly. A&O x4, mood is stable

and no signs of acute distress noted.

HEENT:

Head: Normocephalic, no depressions, scars, masses, hematomas or lesions. Hair distribution

normal.

Eyes: 20/20 vision using Snellen chart. No exophthalmos, ptosis, redness or discharge

bilaterally. Conjunctiva Pink, sclera is white. Extraocular movement intact bilaterally. Pupils

round and reactive to light bilaterally, red reflex visualized. Normal convergence and

accommodation bilaterally. L and R fundoscopic exams revealed bright orange disc with sharp

disc margin, disk to cup ratio 1:3, no hemorrhage or exudate, no AV nicking.

Ears: CN VIII intact, Rinne, Weber, and Whisper test all normal bilaterally. No bleeding,

drainage, inflammation or obstruction noted from the external ear. No tenderness noted upon

palpation of external ears and tragus. A pearly grey tympanic membrane visualized and cone of

light in left ear at 7 o’clock and right ear at 5 o’clock. The malleolus bone visualized bilaterally

with no redness, bulging or discharge noted.

Nose: Nose is patent, no visual obstructions. No tenderness upon palpation of the maxillary and

frontal sinuses. Nasal mucosa pink and wet, no sinus draining. Septum midline with no polyps

noted.

Mouth/Throat: Moist buccal mucosa, no wounds visualized. Adequate dental hygiene, no

dentures or abscesses noted, gingiva without inflammation or redness. Tongue midline, no

deviation, no enlargement. Tonsils are red, swollen to +3 with white patches, uvula midline,

inflamed and red, pharynx erythematous. Petechiae on soft palate. Thyroid is smooth without

nodules or goiter.

Heart: S1 and S2 auscultated, no S3 or S4 heard. No murmurs or palpitations heard.

Respiratory: No audible wheezing, rhonchi or crackles.

Lymph: Anterior and posterior cervical lymph nodes were enlarged upon palpation, they are

moveable with no immovable nodules noted.

Skin: warm and dry, no visible bruising, rashes, no dry patches of skin visualized, no jaundice.

Neurological: Patient is alert and awake and appropriately communicating and engaged. Gait is

steady with no unilateral weakness.

Assessment:

Differential Diagnosis

1. Strep throat-The most common symptoms for Group A streptococci is fever, sore throat,

inflamed swollen tonsils with white patches, and red inflamed pharynx which causes

increased pain and soreness in throat making it difficult to swallow (Bickley, 2021).

Patient was around a friend who had a sore throat as well which he later tested positive

for streptococci group A. Pending the strep test, this diagnosis is most likely.

2. Allergic rhinitis-ruled out due to common signs and symptoms being nasal congestion,

sneezing and clear nasal discharge when exposed to irritants such as smoke, pollen, mold,

animal dander, dust mites, indoor inhalants such as hair spray or other aerosol products.

(Cash & Glass, 2017) Patient is not complaining of any of these symptoms and denies

allergies.

3. Epstein-Barr virus-this virus presents with classic symptoms such as fever, pharyngitis,

lymphadenopathy and extreme fatigue for several months (Cash & Glass, 2017). The

spread is through saliva and most commonly through intimate contact with someone who

also has had the virus or who is currently infected with the virus. Other possible signs and

symptoms are generalized ache, headache, diarrhea which the patient has not complained

of. I am leaning towards strep throat but cannot rule out Epstein-barr as a possibility.

Diagnosis: Strep throat as evidence by the common symptoms of fever, swollen inflamed tonsils

with white patches, sharp throat pain, decreased appetite, no cough or drainage present (Centers

for Disease Control and Prevention, 2018).

Plan:

Diagnostic Plan: Rapid strep test; if negative, then perform throat culture and sensitivity. Throat

culture and sensitivity are the gold standard for diagnosis. Mono spot test to rule out Epstein-

Barr (Cash & Glass, 2017)

Therapeutic Plan:

1. Penicillin V potassium-500 mg twice daily for 10 days. (Rosenthal & Burchum, 2021)

2. Hot tea, soup, and throat lozenges soothe your throat.

3. Avoid smoking and secondhand smoke.

4. Rest or nap as often as possible while you are sick.

5. Diet: Eat a healthy diet. If swallowing is difficult, eat soft foods such as ice cream, Jell-

O, pudding, and soup. Avoid salt and spicy foods. Increase your fluid intake to 10 to 12

glasses a day.

(Cash & Glass, 2017)

Referrals

none

Education and Follow up Plan:

1. Do not go back to work until a full 24 hours of antibiotic treatment has been completed.

If symptoms do not improve in 3 to 4 days, come back to office and recheck patient.

2. Penicillin V can be taken with meals.

3. If patient is experiencing any rashes, hives, itching, hoarseness, wheezing, difficulty

breathing, swelling of the tongue, throat or lips they need to discontinue immediately and

go to the ER for a possible anaphylaxis reaction.

4. Side effects include diarrhea, nausea, vomiting, abdominal pain and a black, hairy tongue.

5. If patient has severe diarrhea (watery or bloody stools) that may occur with or without

fever and stomach cramps (may occur up to 2 months or more after your treatment), call

PCP for a follow up.

6. Follow up appointment in 2 weeks.

7. Use disposable tissues when sneezing. Use tissues when you blow your nose. If no tissue

is available, do the “elbow sneeze” into the bend of your arm (away from your open

hands). Dispose of tissues and then wash your hands.

Reference

Bickley, L. S. (2021). Bates’ Guide to Physical Examination and History Taking. (13th

ed.) Wolters-Kluwer.

Cash, J., & Glass, C. (2017, January 13). Family Practice Guidelines, Fourth Edition . Barnes &

Noble. https://www.barnesandnoble.com/w/family-practice-guidelines-fourth-edition-jill-c-

cash/1125431688.

Centers for Disease Control and Prevention. (2018, November 1). Pharyngitis (Strep Throat):

Information For Clinicians. Centers for Disease Control and Prevention.

https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html#:~:text=Penicillin%20or

%20amoxicillin%20is%20the,treat%20group%20A%20strep%20pharyngitis.

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice

nurses and physician assistants. Elsevier.