Focused SOAP Note: Painful Swallowing Essay Assignment

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Focused SOAP Note: Painful Swallowing Essay Assignment

Focused SOAP Note

Patient Information:

Name: J.

Age: 13 years

Sex: Male

Subjective Data

Chief Complain: Painful swallowing

History of Presenting Illness

The patient is a 3-year-old male who reports painful swallowing that started yesterday as an awful sore throat and was aggravated with swallowing. The patient’s tonsils are 2+ and erythematous, and tonsil stones were noted on the right side. The tongue has white patches. The patient also states to be very tired. The symptoms aggravate at night, and despite the administration of children’s Motrin, only the fever was calmed but did not calm the sore throat.

Medications:

Motrin 100mg to relieve the inflammation and fever Focused SOAP Note: Painful Swallowing Essay Assignment

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Past Medical History

Positive history of aspiration pneumonia managed at six years.

Family History: The mother is asthmatic, and the father has a history of hypertension.

Social History: No history of alcohol or cigarette smoking

Allergies: No history of medicinal, environmental and food allergies

Immunizations: Up to date with immunizations

Review of Systems

General Examination: Body fatigue and fever

Cardiovascular system: Negative for upper and lower extremity edema, orthopnea, and paroxysmal nocturnal dyspnoea. The patient denies chest pain or palpitations.

Pulmonary system: Negative for hemoptysis, intermittent dyspnea on exertion, cough, sputum, and shortness of breath

Gastrointestinal system: Tonsils 2+, positive tonsil stones, white patches on the tongue. Denies anorexia, abdomen pain, nausea or vomiting and diarrhoea.

Lymphatics: Enlarged tonsils and cervical lymph nodes.

Objective Data

Blood Pressure: 109/76

Respiratory Rate: 15

Pulse Rate: 92 bpm

Temperature: 100.5 F

Weight: 107 lbs

Height: 62.3”

General: The patient appears weak and shaky

Cardiovascular: PMI at 4th intercostal space at the left midclavicular line. No clubbing or cyanosis, and negative for edema. Focused SOAP Note: Painful Swallowing Essay Assignment

Pulmonary: Clear to bilateral percussion and auscultation

Gastrointestinal: Normal quality and intensity of bowel sounds, Symmetrical and non-distended abdomen, no mass noted on palpation

Diagnostic Results

Reactive on the rapid strep test. Tonsilitis is diagnosed by observing the tonsil grade, pain in swallowing, and evidence of erythematous tonsil. The rapid strep test increases the molecular test sensitivity and specificity in the molecular tests. Besides, culture and sensitivity can take several days as opposed to the rapid test, which takes several minutes to identify the bacterial.     Weinzierl et al. (2018) advocated for a rapid antigen Group A streptococcus test kit for quick identification and treatment.

Assessment

Differential Diagnosis

  1. Tonsilitis (Tonsilitis is diagnosed from enlarged lymph nodes (2+), erythematous tonsils, white patches on the tonsil, sore throat, painful swallowing and fever (Weinzierl et al., 2018)
  2. Epstein Barr Virus (The patient was marked with fatigue, fever, swollen tonsils and lymph nodes and sore throat. However, mononucleosis from Epstein Barr Virus does not recover on antibiotic administration (Wilson & Wilson, 2021))
  • Scarlet Fever (The patient had a fever associated with a sore throat and exhibited body malaise associated with Scarlet Fever. However, Scarlet fever is marked by a characteristic Scarlet spots, an initial sign of rash (Wilson & Wilson, 2021).
  1. Peritonsillar Abscess (The patient reported painful swallowing, enlarged tonsils, fever and chills, which are characteristic of peritonsillar abscess (Galioto, 2017)
  2. Tonsil cancer (The evidence of painful swallowing, chewing and speaking, sore throat that is not relieved. Tonsil cancer can lead to one enlarged tonsil or blood in saliva (Adil et al., 2018)) Focused SOAP Note: Painful Swallowing Essay Assignment

Primary or Presumptive Diagnosis: Tonsilitis

 

 

References

Adil, E. A., Medina, G., & Cunningham, M. J. (2018). Pediatric tonsil cancer: a national and institutional perspective. The Journal of pediatrics, 197, 255-261. https://doi.org/10.1016/j.jpeds.2018.01.022

Galioto, N. J. (2017). Peritonsillar abscess. American family physician, 95(8), 501-506. https://www.aafp.org/pubs/afp/issues/2017/0415/p501.html

Weinzierl, E. P., Jerris, R. C., Gonzalez, M. D., Piccini, J. A., & Rogers, B. B. (2018). Comparison of Alere i Strep A rapid molecular assay with rapid antigen testing and culture in a pediatric outpatient setting. American Journal of Clinical Pathology, 150(3), 235-239. https://doi.org/10.1093/ajcp/aqy038

Wilson, M., & Wilson, P. J. (2021). Sore Throat. In Close Encounters of the Microbial Kind (pp. 197-212). Springer, Cham. https://doi.org/10.1007/978-3-030-56978-5_13

As we move to week 5, we will begin assessment of the Head, Neck, Eyes, Ears, Nose and Throat. It is imperative that we learn proper assessment of these areas to form proper diagnoses.

Your first assignment this week will be a case study. Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case. You will need to put in the missing information in the note (some may be made up ie meds, hx, parts of the ROS and PE). I’m looking to make sure you know what information to include. In the Assessment/Plan, you will document your differential diagnoses as per the assignment. Document the assignment on the Episodic/focused SOAP note exemplar located in the Resource list. Focused SOAP Note: Painful Swallowing Essay Assignment

 

Assignment 1

The Assignment

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each (this means diagnoses related to EENT and the patient’s chief complaint).

 

You are to remain in the same group as you were previous assigned. This paper should include a separate title and reference page using APA format.
Jason, a 13 year old male comes in with Mom complaining of painful swallowing. Started yesterday as a “really bad sore throat” made worse with swallowing. He reports feeling very tired. His Mom gave him over-the-counter Children’s Motrin which made his fever better but did not help sore throat. He reports his symptoms are especially, worse during nighttime. His tonsils are 2+ and erythematous, tonsil stones are present on the right side. He has white patches on his tongue. Focused SOAP Note: Painful Swallowing Essay Assignment