Comprehensive SOAP Note

Type: Case Study 

Subject: Acute Care Nurse Practitioner 

Subject area: Nursing 

Education Level: Masters Program 

Length: 2 pages 

Referencing style: APA 

Preferred English: US English 

Spacing Option: Double 

Patient Information

Initials: P.T

Age: 20

Sex: Female  

Race: Caucasian 

Subjective.

CC: “For the last two days, I have had sore throat, decreased appetite, pain when swallowing food and headache.”

HPI: Ms. P.T is 20 years of age, a social worker with the Los Angeles Social Work department. She presented with sore throat which has been for the past two days. Additionally, she complained decreased appetite, pain when swallowing food and headache. She notes that she has had flu-like symptoms which had affected almost all the social work department prompting them to take sick leaves. She also recounts have running nose discharge when she started her illness. She therefore went with medicines over the counter where she was prescribed to; Tylenol and Chlorasepctic lozenges but she did not get any better relief (O’Hanlon & Shaw, 2019). 

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Also Read: Nursing Case Study Writing Help

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Location: Throat and Headache. 

Onset: 2 days ago

Main Character: sore throat.

Associated Signs and Symptoms: Headache, Decreased Appetite, and Pain with Swallowing. 

Timing: Constant 

Exacerbating Factors: Tylenol slightly improves the situation but does not completely alienate the condition. 

Severity: 7/10 pain scale.

Problem-Specific Questions:

1. Have you been Coughing with running fever or exhibiting chills?
2. Have you ever smoked?
3. Does it hurt when swallowing solids, liquids, or both?
4. Do you cough or choke when swallowing?
5. What have you eaten in the last twenty-four hours? 

Current Medication: Blisovi Fe 1/20 1 tab daily and Multivitamins 1 tablet daily (O’Hanlon & Shaw, 2019).

Allergies: None.

PMHx: She denies past hospitalization. She also denies any history of accidents/injury or falls.

Soc Hx: Ms P.T is a social worker working at the Los Angeles social work department and currently deployed to various nursing homes. She works in various nursing homes and takes a break on weekends. She is single, heterosexual and sexually active. She constantly exercises 2x/week and eats balanced meals. She drives a vehicle and always puts on her seatbelt. Never smoked or use alcohol. 

Fam Hx:

Maternal Grandmother: deceased at age 83 by car accident

Maternal Grandfather: deceased at age 90, normal old age death

Paternal Grandmother: deceased at age 70, related to stroke 

Paternal Grandfather: deceased at age 102, no health condition noted 

Mother: age 60, no health conditions reported 

Father: age 65, has diabetes and high blood pressure. 

Siblings: She has 2 sisters age 14 and 12. 

Review of Systems: 

GENERAL:  The patient is awake, alert, oriented and appears generally well. 

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclera. No decreased hearing. No hearing loss, sneezing, or congestion. Has complaints of runny nose, sore throat and headaches

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Respirations are regular and unlabored. No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. Complaints of decreased appetite

GENITOURINARY:  Denies burning in urination, never been pregnant. Menses are regular, last menstrual period, 20.12.2022.

NEUROLOGICAL:  No dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. Complains of headache that started with the onset of sore throat.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness. Episodic/Focused SOAP Note Template Examples.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No history of splenectomy. Swollen nodes in the neck

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No allergies reported. 

Objective 

Vital signs: Ht. 5’10”, Wt. 120 lbs; BMI= 20.5; pulse of 96, respirations of 18, temperature of 101.6 and O2 saturation on room air of 98%.

HEENT: Pupils are equal, round and reactive to light normally. There is no sinus tenderness. Ears are clear. Throat is slightly red with some swelling. Running nose with clear lungs. Heart rates are normal without any murmur or galloping. Abdomen is normally soft and non-tender. No organomegaly presented. Extremities: No edema. Skin/Hair/Nails: Normal color for ethnicity and turgor without rash. 

Diagnostic results: Throat swab was obtained and set to the lab for the following tests; rapid strep testing, rapid influenza diagnostic testing, follow-up throat culture. 

Assessment.

Differential Diagnoses

Possible Influenza outbreak: Many of her work colleagues complained with flu-like symptoms which must be domiciled within the Nursing homes; however, this is pending in its diagnostics and analysis (Lennon et al., 2021). Additionally, the patient is exhibiting sore threat, fever, headache and nasal discharge. 

Group A streptococcal pharyngitis: This is due to the sore throat condition but will need more tests to check on possible erythematous and exudative tonsils and uvula. 

Diphtheria: clinical manifestations include sore throat, headache, malaise and low-grade fever. 

Epstein-Barr virus (EBV) infectious mononucleosis: This virus spread most commonly through bodily fluids, especially saliva. Though classic signs of EBV is prolonged malaise, sore throat is a very prevalent sign, and the condition more common for those between ages 15-30 years (Lennon et al., 2021).

Primary Diagnoses

Possible Influenza outbreak

References

Lennon, R. P., Miller, E. L., Snyder, B., & Van Scoy, L. J. (2021). Self-reported influenza and influenza-like symptoms in US adults age 18–64 between September 1, 2019 and April 15, 2020. Journal of Clinical Virology, 134, 104709. 

O’Hanlon, R., & Shaw, M. L. (2019). Baloxavir marboxil: the new influenza drug on the market. Current opinion in virology, 35, 14-18.