Tonsillitis SOAP Note Assignment

Tonsillitis SOAP Note Assignment

Tonsillitis SOAP Note Assignment

CC (Chief Complaint): “I have a sore throat causing painful swallowing.”

HPI: M.D is a 14-year-old male patient who presents with complaints of a sore throat causing painful swallowing. The sore throat began three days ago as a tingling sensation and has worsened to cause difficulty and painful swallowing. He also reports hotness of the body that started two days ago. The painful swallowing is worse when eating solid foods, and he is now on a liquid diet. He states that he took OTC Tylenol to alleviate the high body temperatures and painful swallowing, and it lowered the fever to some degree, but the painful swallowing persisted. He rates the painful swallowing as 5/10.

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Medical History: No history of chronic medical illness or frequent infections.

Surgical History:  History of an I&D on the left upper limb at 8 years.

Medications: No current medications.

Allergies: Allergic to Sulfur- It causes a rash.

Immunization History: The vaccination schedule is up to date. The last Influenza shot was four months ago.

Family History: The patient’s maternal grandfather has Hypertension and has a history of a heart attack. His younger brother has Asthma. The parents are alive and well.

Social History:  M.D is a Grade 9 student and lives with his parents and siblings. He is the second born in a family of three. His hobbies include playing baseball and painting. He reports eating at least three meals a day and sleeps about 9 hours. He denies being bullied in school.

ROS (Review of systems)

General: Reports fever. Denies weight gain/loss, body weakness, fatigue, or chills.

HEENT: Head: Denies head trauma. Eyes: Negative for visual changes, blurred/double vision, eye pain, or excessive tearing. Ear: Denies ear pain, discharge, or hearing loss. Nose: Throat: Denies rhinorrhea, nasal discharge, sinus pain, or nosebleeds. Throat: Reports sore throat, painful swallowing, and swallowing difficulty.

Neck: Report neck stiffness and pain.

Skin: Denies rashes, itching, or bruises.

Cardiovascular: Negative for chest pain, palpitations, dyspnea on exertion, or edema.

Respiratory: Negative for cough, sputum, chest pain, difficulties in breathing, or wheezing.

GI: Denies heartburn, regurgitation, epigastric pain, nausea/ vomiting, abdominal pain, constipation/diarrhea, or rectal bleeding.

Genitourinary: Negative for penile discharge, urinary frequency or urgency, painful urination, abnormal urine color, or blood in the urine.

Musculoskeletal: Negative for muscle pain, joint pain/stiffness, enlarged joints, or difficulties in movement.

Neurological: Denies headache, black spells, dizziness, fainting, or burning sensations.

Endocrine: Denies excessive sweating, heat/cold intolerance, increased urine production, acute thirst, or excessive hunger.

Hematologic: Negative for bleeding or bruising.

Allergic/Immunologic: Denies hives or allergic illnesses. 

Objective

Vital signs: BP- 110/72; HR- 80; RR-20; Temp- 100.76; Ht- 5’3; Wt- 110 lbs.; BMI- 20.1

General:  Male adolescent patient in no acute distress. He is alert and oriented. The patient is appropriately dressed and neat. He maintains eye contact and his speech is clear. Normal gait and posture.

HEENT: Head: Atraumatic and symmetrical; Eyes: Sclera is white, No conjunctiva pallor, PERRLA; Ear: TMs are shiny and intact; Nose: No rhinorrhea or nasal secretions. Throat: Enlarged, inflamed tonsils with exudates

Neck:  Full neck ROM. The trachea is symmetrical and mid-line. Tender anterior cervical lymph nodes and neck stiffness

Cardiovascular: No edema or jugular vein distension. Normal heart rate and rhythm with S1 and S present. No systole or friction rubs.

Respiratory: Smooth and uniform respiratory movements. The chest is clear on auscultation.

Diagnostic results:  Rapid antigen test- Positive. The test is used to confirm or rule out infection with Group A beta-hemolytic streptococcus (GABHS) (Anderson & Paterek, 2021).

Assessment/Plan

Differential List

Infectious Mononucleosis (MN): Clinical manifestations of Epstein-Barr virus (EBV) infectious MN include sore throat with red swollen tonsils, fatigue, prolonged malaise, nausea, anorexia, and fever that can reach 103-104°F. Infectious Mononucleosis is a differential based on positive symptoms of sore throat, inflamed tonsils, and fever. However, it is an unlikely diagnosis since the patient has no infection with Epstein-Barr virus.

Scarlet Fever: Clinical manifestations include fever (101-104 F), sore throat, fatigue, headache, nausea/vomiting, abdominal pain, flushed face with perioral pallor, and tachycardia. Physical exam findings include enlarged lymph nodes, red macules on the hard and soft palate and uvula, and bright red tongue. Scarlet fever is a differential diagnosis based on symptoms of sore throat, fever, and anterior cervical lymphadenopathy. However, the patient has no strawberry tongue and instead has inflamed tonsils, which rules out Scarlet fever as a primary diagnosis.

Working Diagnosis

Tonsillitis: Tonsillitis is characterized by inflammation of the palatine tonsils. Clinical features of Tonsillitis include sore throat, fever, foul breath, difficulty swallowing, painful swallowing, and tender cervical lymph nodes. Physical findings include fever, red and swollen tonsils, often with purulent exudates, and tender cervical lymphadenopathy can be present (Anderson & Paterek, 2021). Besides, fever, palatal petechiae, adenopathy, and exudates occur more often with GABHS. Tonsillitis is the presumptive diagnosis based on the patient’s history of fever, Tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough (Anderson & Paterek, 2021). In addition, the symptoms of sore throat, painful swallowing, and difficulty swallowing point to Tonsillitis.

Problem: Tonsillitis

Plan

Further Diagnostic Testing: CT scanning will be indicated if the acute Tonsillitis is suspected of spreading to deep neck structures and in the case of peritonsillar abscess (Pérez et al., 2020).

Pharmacologic therapy:  Augmentin 500/125 mg PO twice daily for 10 days. GABHS infection requires comprehensive antibiotic coverage (Pérez et al., 2020).

Motrin 200 mg PO TDS for 3 days. Motrin is an NSAID indicated to alleviate inflammation and fever.

Non-pharmacologic therapy: Supportive management will focus on maintaining adequate caloric intake and hydration and alleviating pain and fever. He will be encouraged to have adequate oral hydration with warm fluids (Anderson & Paterek, 2021).

Patient education: The patient will be advised to have adequate rest to accelerate recovery. He will also be educated on the desired outcomes of the antibiotic therapy and potential side effects of treatment (Pérez et al., 2020).

Follow-up: The patient will be followed-up after 14 days to assess response to treatment and any complications

References

Anderson, J., & Paterek, E. (2021). Tonsillitis. In StatPearls [Internet]. StatPearls Publishing.

Pérez, R. P., González, F. Á., Baquero-Artigao, F., Cañete, M. C., i Bru, J. D. L. F., Landaluce, A. F., … & Fernández, J. S. (2020). Diagnosis and treatment of acute tonsillopharyngitis. Consensus document update. Anales de Pediatría (English Edition), 93(3), 206-e1. https://doi.org/10.1016/j.anpedi.2020.05.004

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Assessment Description
Using the condition you posted about in DQ 1 this week, provide a SOAP note using the format outlined below. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources. You may not select a condition or disorder that has already been profiled by another learner; you must select a different one.

Subjective

CC (Chief complaint)
HPT (History of present illness)
History (Pertinent medical, surgical, social, medications, exposure, family history, allergies, vaccines)
ROS (Review of systems)
Objective

Vital signs/BMI
Physical exam findings
Diagnostic results (include actual “results” or “findings” that you would expect for a certain scenario)
Assessment/Plan

Differential list and rationale for final/working diagnosis
Problem list
Plan for Each Problem

Based on evidence with proper references
Further diagnostic testing you would order
Nonpharmacologic therapy
Pharmacologic therapy, including specific medication dose
Frequency and duration of therapy
Patient education
Follow-up

THE SOAP NOTE WILL BE ON TONSILLITIS IS MY TOPIC FOR THIS WEEK THANK YOU PLEASE SITE SOURCES IN THE DIAGNOSTICS TEST AND LAB TEST THANK YOU