Episodic SOAP Note Case Study Assignment Discussion

Episodic/Focused SOAP Note

Patient Information:

M.B., 9 years, Male

S.

CC: The patient presents with a sore throat that started yesterday and felt warm. The patient did not check their temperature.

HPI: M.B., a 9-year-old male, presents to the clinic with his father and siblings complaining of a sore throat since yesterday. He describes feeling warm at times. He denies nasal drainage, cough, headache, upset stomach, or eye drainage. His appetite is normal, but he reports pain upon swallowing. Siblings are also experiencing similar symptoms.

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Location: Throat Onset: Started yesterday

Character: Soreness, warmth

Associated signs and symptoms: Denies nasal drainage, cough, headache, upset stomach, or eye drainage. Reports pain upon swallowing. Siblings also experiencing similar symptoms.

Timing: Since yesterday

Exacerbating/relieving factors: Not specified

Severity: Not specified

Current Medications: Amoxicillin 400 mg/5 mL oral liquid, 6.25 mL every 12 hours, prescribed for strep throat.

Allergies: Gentamicin ophthalmic (specific reaction not mentioned)

PMHx: Ongoing strep pharyngitis and Circumcision

Soc & Substance Hx (Social & Substance History): Episodic SOAP Note Case Study Assignment Discussion

Lives with father, mother, and siblings.

No alcohol use reported.

No electronic cigarette/vaping reported.

One cat in the household.

Regular nutrition, no dietary restrictions.

Sleep without concerns reported.

Fam Hx:

Mother has a history of heart attack.

Mother has a history of Von Willebrand disease.

Surgical Hx: Circumcision

Mental Hx: There’s no mention of this in the case study

Violence Hx: There’s no mention of this in the case study

Reproductive Hx: Not applicable as the patient is a 9-year-old male.

ROS:

GENERAL: Well-appearing, in no distress.

HEENT:

Head: Normocephalic, atraumatic.

Eyes: Conjunctivae clear, sclera non-icteric.

Ears: External auditory canals clear. Tympanic membranes within normal limits.

Nose: Bilateral patent nares, green rhinorrhea.

Throat: Moderate erythema, tonsils +3 with crypts.

SKIN: Warm, dry, and good turgor.

CARDIOVASCULAR: Regular rate and rhythm, no murmurs.

RESPIRATORY: Clear to auscultation bilaterally, no wheezes, rhonchi, or rales. Breathing unlabored.

GASTROINTESTINAL: Abdomen soft, non-tender, non-distended, no hepatosplenomegaly or masses.

GENITOURINARY: Not assessed in the provided case study.

NEUROLOGICAL: Not assessed in the provided case study.

MUSCULOSKELETAL: Not assessed in the provided case study.

HEMATOLOGIC: Not assessed in the provided case study.

LYMPHATICS: Not assessed in the provided case study.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: Not assessed in the provided case study

REPRODUCTIVE: Not applicable as the patient is a 9-year-old male.

ALLERGIES: Gentamicin ophthalmic. Episodic SOAP Note Case Study Assignment Discussion

O.

Physical Exam:

General:

Appearance: Well-appearing, no distress.

Skin: Warm, dry, with good turgor.

HEENT:

Head: Normocephalic, atraumatic.

Eyes: Conjunctivae clear, sclera non-icteric.

Ears: External auditory canals clear. Tympanic membranes within normal limits.

Nose: Bilateral patent nares, green rhinorrhea.

Throat: Moderate erythema, tonsils +3 with crypts.

Cardiovascular:

Heart: Regular rate and rhythm, no murmurs.

Respiratory:

Lungs: Clear to auscultation bilaterally, no wheezes, rhonchi, or rales. Breathing unlabored.

Diagnostic Results:

1. Strep A (GeneXpert) test: Positive
2. CT Scan: Abnormal (specific findings not provided)

According to guidelines by Mustafa and Ghaffari (2020), patients presenting with sore throat symptoms should have a fast strep test performed to confirm the diagnosis of streptococcal pharyngitis. Positive findings suggest the presence of germs and call for the use of antibiotics. Furthermore, if there are worries about complications or an unusual presentation of the disease, imaging examinations like a CT scan may be requested; however, the case study does not disclose particular results from the CT scan.

A.

Primary Diagnosis: Streptococcal Pharyngitis (Strep Throat)

Streptococcal pharyngitis is a frequent bacterial infection caused mostly by Group A Streptococcus (GAS) bacteria. It is characterized by a painful throat, a high body temperature and frequent tonsillar exudates. The major diagnostic test is the fast strep test, which identifies group A streptococcal antigens in throat swabs. The Infectious Diseases Society of America (IDSA) recommends quick identification and treatment with antibiotics such as amoxicillin or penicillin to avoid problems and transmission (Tanael, 2020). The recommendation recommends starting therapy in individuals with a positive quick strep test to relieve symptoms and reduce the risk of rheumatic fever and suppurative consequences (Mustafa & Ghaffari, 2020).

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Differential Diagnoses:

1. Viral Pharyngitis

Viral pharyngitis, commonly caused by adenovirus, influenza virus, or rhinovirus, presents with similar symptoms to streptococcal pharyngitis but typically lacks tonsillar exudates. Diagnosis is often clinical, with supportive management focusing on symptom relief. Antiviral medications may be considered in high-risk patients or during outbreaks (Sykes et al., 2020).

2. Infectious Mononucleosis (IM)

The Epstein-Barr virus (EBV) is the cause of infectious mononucleosis, which can manifest as lethargy, sore throat, fever, and lymphadenopathy. Diagnosis is confirmed through serological tests like the monospot test or EBV-specific antibody testing. Management includes supportive care, as antibiotics are ineffective against viral infections like IM (Naughton et al., 2021)Episodic SOAP Note Case Study Assignment Discussion.

3. Acute Retroviral Syndrome (ARS)

Acute retroviral syndrome, the initial presentation of human immunodeficiency virus (HIV) infection, may manifest with symptoms resembling streptococcal pharyngitis, including sore throat and fever. Diagnostic testing includes HIV antigen/antibody testing or nucleic acid testing. Early detection is crucial for timely initiation of antiretroviral therapy (AVA), as outlined in the guidelines from the Department of Health and Human Services (DHHS) (Gabert et al., 2023).

1. Strep Pharyngitis:

1. 1. Diagnostic Studies: Already confirmed with positive rapid strep test.
   2. Therapeutic Interventions: Initiate treatment with amoxicillin 400 mg/5 mL oral liquid, 6.25 mL every 12 hours for 10 days as prescribed.
   3. Education: Educate patient and family on the importance of completing the full course of antibiotics, proper hygiene practices to prevent spreading infection, and when to seek medical attention if symptoms worsen.
   4. Follow-up: Schedule a follow-up appointment in 1 week to assess response to treatment and resolution of symptoms.

1. Management of Symptoms:

1. 1. Recommend acetaminophen or ibuprofen as needed for pain and fever.
   2. Advise rest and increased fluid intake to support recovery.
   3. Change toothbrush within 24-48 hours to prevent re-infection.

1. Referral: No immediate referral necessary. However, if symptoms worsen or complications arise, consider referral to an otolaryngologist for further evaluation and management.

Reflection:

In this case, the course of therapy is in accordance with evidence-based recommendations for the handling of strep throat. According to Di Muzio et al. (2020), amoxicillin is a suitable antibiotic to treat bacterial illnesses like streptococcal pharyngitis. For patients to comply with treatment and to stop the illness from spreading to others, it is crucial to place a strong focus on education on completing the entire course of antibiotics and good cleanliness habits.

Reflecting on this case, I agree with the treatment provided by my preceptor. However, I learned the importance of considering potential complications such as peritonsillar abscess, especially in cases of severe sore throat. In the future, I would ensure thorough assessment for signs of complications and consider imaging studies if necessary.

In the context of illness prevention and health promotion, patient characteristics like age, socioeconomic level, and cultural background are critical. In this instance, promoting good hygiene habits among the patient and their family and getting medical care as soon as possible will help limit the propagation of illnesses within the community and at home.

Reference

Di Muzio, I., d’Angelo, D. M., Di Battista, C., Lapergola, G., Zenobi, I., Marzetti, V., … & Altobelli, E. (2020). Pediatrician’s approach to diagnosis and management of group A streptococcal pharyngitis. European Journal of Clinical Microbiology & Infectious Diseases, 39, 1103-1107. https://doi.org/10.1007%2Fs00431-023-05211-w

Gabert, R., Lama, J. R., Valdez, R., Dasgupta, S., Cabello, R., Sanchez, H., … & Duerr, A. (2023). Acute retroviral syndrome is associated with lower CD4+ T cell nadir and delayed viral suppression, which are blunted by immediate antiretroviral therapy initiation. AIDS, 37(7), 1103-1108. https://doi.org/10.1097/qad.0000000000003511 Episodic SOAP Note Case Study Assignment Discussion

Mustafa, Z., & Ghaffari, M. (2020). Diagnostic methods, clinical guidelines, and antibiotic treatment for group A streptococcal pharyngitis: a narrative review. Frontiers in Cellular and Infection Microbiology, 10, 563627. https://doi.org/10.3389/fcimb.2020.563627

Naughton, P., Healy, M., Enright, F., & Lucey, B. (2021). Infectious Mononucleosis: diagnosis and clinical interpretation. British journal of biomedical science, 78(3), 107-116. https://doi.org/10.1080/09674845.2021.1903683

Sykes, E. A., Wu, V., Beyea, M. M., Simpson, M. T., & Beyea, J. A. (2020). Pharyngitis: approach to diagnosis and treatment. Canadian Family Physician, 66(4), 251-257.

Tanael, M. (2020). Pharyngitis guidelines and missional goals. Military Medicine, 185(9-10), e1341-e1342. https://doi.org/10.1093/milmed/usaa056

Will upload Patient INFO and SOAP TEMPLATE

Assignment

• Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
• Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
• Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation? Episodic SOAP Note Case Study Assignment Discussion

RUBRIC

RAC_6541_Week3_Assignment2_Rubric

Episodic SOAP Note Case Study Assignment Discussion