Example.docx

Running head: EPISODIC NOTE 1

EPISODIC NOTE 3

Episodic Note

Focused SOAP for a patient with throat pain

S.

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

ROS:

· 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

O.

Gastrointestinal: There is no distention in the belly, and bowel movements are in all locations.

Pulmonary: Both lungs are open to percussion.

Diagnostic results:

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) .

Differential diagnoses

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.

References

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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