NUR 613 SOAP NOTE 3 Peds sore throat

SOAP Note Week Three

ID: C.B.  DOB 09/01/2009, age 14, White male presents to the clinic with his mother. 

Subjective: 

CC: “Sore throat for 3 days, eyes watery, and a runny nose”

HPI:

Pt c/o sore throat and voice is raspy, denies any fevers.

• Location: throat and nose
• Quality: throat hurts
• Severity: acute, “6 out of 10”
• Timing: started on Thursday, today is Saturday
• Setting: hurts all the time
• Alleviating and aggravating factors: nothing alleviates the pain right now and swallowing aggravates right now.
• Associated signs and symptoms: The mother says his throat has been red, and his nose has been runny. 

Past Medical History:

• Medical problem list 

No past medical problems

• Surgical: 

No past surgeries

Allergies: 

No known drug allergies

Food allergies: no known food allergies

Denies seasonal allergies.

Medications: 

Denies being on any medications.

Vaccinations: 

Received all childhood vaccines.

Received 2 Covid-19 Vaccines

Does not receive the Flu vaccine.

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Social History:

• Marital Status: Single
• Occupation: Student and Agriculture Field Worker (rouging and detasseling) in the summer
• Education: 8th grader at middle school
• Lifestyle: Lives with his parents and has fun hanging out with his friends and family. Plays baseball (No need to capitalize) on a traveling team, he plans to play basketball this year and decided not to play football this year, he wants to focus on baseball more. He has 2 dogs and 1 cat. 
• Religion: Lutheran
• Sexual history: 

• Denies ever having sex or kissing a girl yet.

• Chemical history: 
  • Denies ever trying or using tobacco/e-cigarette or illicit drug use.
  • Denies ever trying or drinking any alcohol. 

Family History:

  Mother ag 34-no medical problems

  Father age 33- no medical problems
  Sister 1-age 11- no medical problems

  Sister 2-age 8- no medical problems
  Maternal Grandma-58- no medical                    problems

Maternal Grandfather-60- no medical problems

Paternal Grandmother-53- no medical problems

Paternal Grandfather-57- no medical problem

ROS: 

General/Constitutional: Pt c/o sore throat and a runny nose, with no fever. Denies any headaches, chills, or fatigue.   

Eyes: Pt states his eyes have been watery the last couple of days. Denies vision problems, states vision is 20/20 without corrective lenses last eye exam was summer of 2023.
Ears/Nose/Throat/Mouth: Denies having any earaches. (+) sore throat and denies any sinus pain. (+) hoarse voice. 

C/V: Denies any chest pain.
Pulmonary: Denies any cough or trouble breathing. 

Neuro: Denies any headaches, dizziness, nausea, or vomiting. 

Lymph: Denies swollen lymph nodes in the neck.

Allergy/immunology: Denies any history of seasonal or environmental allergies. 

Objective

VS: T – 98.7 P – 70 R – 16 BP – 116/78 O2 sat – 99% - 6/10 pain in throat. Wt: 105.6 Ht: 66 1/2 in BMI: 16.9

General/Constitutional: alert and oriented, able to answer questions himself without his mother's input.

Eyes: Conjunctiva clear, sclera is white, PERRLA.  Ears: TM is intact, pearly gray, and with the cone of light bilat, no lesions or masses noted. Nose: mucosa pink clear drainage noted, no sinus tenderness upon palpitation, nares are patent bilaterally and the septum is midline. Throat: mouth mucosa is pink and moist, no masse, the tongue is midline, and the uvula is midline. Tonsils are enlarged but no white spots noted on either tonsil. Neck: non-tender, lymph nodes not palpable. Non-enlarged thyroid is not enlarged and is palpated. The trachea is midline.
Cardio: regular rate and rhythm no murmurs noted, S1 and S2 notes

Respiratory: respirations 16, no noted distress. Auscultation-clear breath sounds, no wheezing/crackles/rhonchi noted throughout. No noted distress with breathing. The chest is symmetric on inspection and palpitation. Diagnostic Testing: 

A strep test was sent in for Culture to the lab to rule out strep throat. 

Assessment: 

Differential DDX:

1. Strep throat [J02.0]– though I tested for strep throat, this is not as likely. He does not hat have signs of ulcerations on his tonsils, he is absent of cough. (Mustafa & Ghaffari, 2020)
2. Seasonal Allergic Rhinitis [J30.2] – sore throat, runny nose, watery eyes (Emerick et, Al., 2019) 
3. Mononucleosis [B27.90]- Symptoms usually include fever, sore throat, fatigue, and tender lymph nodes are classic findings on history-taking in infected individuals with mononucleosis. The incubation period for mononucleosis is long averaging 3-6 weeks and most patients do not recall the exposure. (Mohseni, et, Al., 2023)

DX: seasonal allergic rhinitis

Plan:

• Diagnostics
  • In-house throat swab for strep culture.

• Treatment 
  • Claritin 10mg by mouth once a day 
  • Tylenol 325 1-2 tabs by mouth every 4 hours as needed for pain/discomfort no more than 4,000mgs in 24 hours. 
  • Drink lots of fluids and water

• Education
  • Safe dosing discussed on medication usage. 
  • Avoid pollen and dust where possible, this is harvest season. 
  • Cover mouth when coughing, wash hands after coughing or blowing nose. 

• Follow-up
  • Return to the office in 5-7 days if symptoms do not improve.
  • Call 911 or go to the ER if any trouble with breathing or any other concerns.

             

Emeryk, A., Emeryk-Maksymiuk, J., & Janeczek, K. (2019). New guidelines for the treatment of seasonal allergic rhinitis. Advances in Dermatology and Allergology/Postȩpy Dermatologii i Alergologii, 36(3), 255-260. https://doi.org/10.5114/ada.2018.75749

Mohseni M, Boniface MP, Graham C. 2023 Jan. [Updated 2023 Aug 8]. Mononucleosis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; Available from: https://www.ncbi.nlm.nih.gov/books/NBK470387/ 

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. https://doi.org/10.3389/fcimb.2020.563627