SOAP Note: Strep Throat Discussion Paper

Patient information

Patient initials: F.K. Age: 8-year-old         Gender: Male                           Race: Caucasian

S

CC: “Sore throat and fever.”

HPI: F.K, a 7-year-old Caucasian male, presented to the clinic accompanied by his mother with a chief complaint of sore throat and fever, which began two days ago. He was also reported to have throat pain which he rated 7/10. The patient stated that his throat hurts when he tries to swallow. His mother reported to have given him Calpol, but this only gave him minimal relief. He reported having general fatigue but denied issues with the abdominal disorder.SOAP Note: Strep Throat Discussion Paper

Current medication: Calpol 200mg 10ml PO PRN

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PMH: none

Surgical Hx: none reported

Allergy: NKDFA

Immunization: up-to-date. Last received flu vaccine 4/9/21

Family history: paternal grandmother (deceased): COPD. Paternal grandmother (69 y/o): hypertension: maternal grandmother (deceased): CKD

Social history: The patient is the fifth child in a family of six and is currently in second grade at a neighboring school. Has never indulged in illegal substances. He lives in a secure environment with his parents. He eats healthily and enjoys football matches with his friends.

ROS

General: +ve fever, fatigue, and loss of appetite. -ve for weight loss.

HEENT: negative for loss of vision, hearing, and instances of nosebleed. +ve for throat pain.

CV: -ve for chest pain

Resp: +ve for cough. -ve for night sweats

GI/GU: -ve for N/V/D, dysuria, and polyuria

MSK: -ve for muscle pain or weaknesses

Skin: -ve for skin redness or skin rash

Endocrine: -ve for cold or heat intolerances

Allergy/immunologic: -ve for Asthma, Rhinitis, and sensitivity to latex.

Neuro: -ve memory loss and syncope. SOAP Note: Strep Throat Discussion Paper

O

PE:

Vts: Temp 38.6 P.82   RR: 20 BP:  94/112 SpO2 98% Wt. 50lb Ht. 121.3cm

General: he is well-developed and well-nourished. Appear well hydrated.

HENT: normocephalic and atraumatic. A tiny red spot on the roof of the mouth was noted. His throat is red and swollen tonsil noted.

CVS: Quiet precordium, no thrills. Regular S1 and S2. No murmur or gallops (Jarvis et al.,2019).

Respiration: symmetric chest expansion. Clear lung sound noted.

Abdomen: soft and non-tender. Bowels sound normoactive.

Extremities: Warm, no cyanosis or edema. Good skin turgor.

Neurological: negative Brudzinski and Kernig signs

Psych: -ve

A:

Lab test

CBC: result pending

Throat culture: result pending

Rapid strep test: positive

Diagnosis

Differential diagnoses

1. Strep throat
2. Viral pharyngitis
3. Mononucleosis

Primary diagnoses: Strep throat SOAP Note: Strep Throat Discussion Paper

P.

Medication: give Amoxil 200ml 10ml P.O. bid x3 (de Cassan et al.,2020).

Patient education: the patient must adhere to the prescription to avoid developing antibiotic resistance.

Follow–up: if no improvement is noted, the patient will be returned to the clinic for further intervention.

References

Jarvis, C., Browne, A., MacDonald-Jenkins, J., & Luctkar-Flude, M. (2019). Physical examination and health assessment (3rd Canadian ed.).

De Cassan, S., Thompson, M. J., Perera, R., Glasziou, P. P., Del Mar, C. B., Heneghan, C. J., & Hayward, G. (2020). Corticosteroids as standalone or add‐on treatment for sore throat. Cochrane Database of Systematic Reviews, (5). SOAP Note: Strep Throat Discussion Paper