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SOAP Note- Strep Pharyngitis

Institution

Common Illness Across the Lifespan-Clinical Practicum

Professor

SOAP NOTE- Strep Pharyngitis

SUBJECTIVE DATA

Patients ID: John Doe, Aged 25 years. Race: Native American, Gender: male, Date of Birth 12/01/1996, Marital status: married.

CC: “I have been experiencing a burning pain in my throat, fever and a feeling of weakness with high temperatures x 4 days.”

History of present illness: A 25-year-old male patient presents to the clinic today with a complaint of sore throat, red and swollen tonsils with white patches. The patient also complained of painful swallowing with associated fever, headaches, and a decreased appetite. The patient suggested that the condition worsens at night. The condition is also worsening while drinking and eating. He states that the pain is severe and rates 8/10 using the pain scale. He verbalized that he used medics to relent his condition other than ibuprofen (Advil). The patient reverts contacts with sick persons, but he reports that he attended a soccer tournament at his brother’s school, where he interacted with many people.

Review of Systems

General: The patient reported no weight loss, weakness, night sweats, chills, fatigue, or malice. However, he has been experiencing fever, mild pain, and decreased appetite.

HEENT: Head; He complains of mild headaches but reverts to light-headedness or dizziness. Eyes; Denies changes in vision, diplopodia, floaters, or excessive tearing, nor does he use glasses for corrective vision. Ears; He denies hearing changes, tinnitus, earache, or pressure. Nose; Denies rhinorrhoea, epistaxis, nasal polyps, recent sinus infections, nasal discharge, or postnasal drip. Mouth and Throat; He denied bleeding gums, toothaches, sores in the mouth, changes in taste, hoarseness in voice, or voice changes. However, he reports he has a sore throat, hence difficulties swallowing or chewing.

Neck: He reported swollen glands. He was negative for neck stiffness, masses, pain, or swelling in the neck.

Respiratory: He denied coughs, shortness of breath, wheezing, or respiratory distress.
Cardiovascular: He denied chest pain, palpations, dyspnea, murmurs, or edema.

Gastrointestinal: The patients complained of decreased appetite and stomach upsets. He denied vomiting, diarrhea, or changes in bowel movement, heartburns, hematemesis, abdominal pain, or rectal bleeding.

Genitourinary: Denied urinary frequency, urgency, burning sensation, incontinence, or changes in colour or odour, haematuria, or urinary pattern. The patient’s male genitalia was negative for discharge, negative urine stream, testicular pain, or swellings.

Musculoskeletal: The patient denied pain in joints, swellings, stiffness, muscle pains, or weakness, back pain, or limitations in range of motions.

Neurologic: The patient denied having seizures or changes in memory.

Lymph: The patient reported swollen glands or tenderness.

Endocrine: The patient reverted heat intolerance, weight changes, or fatigue.

Hematopoietic: Negative for bruises or bleeding tendencies.

Psychiatric: The patient denied suicidal ideation, depression, or mental illness attacks.

Past Medical History: The patient reports that at childhood, he had been affected by strep throat and ear infections. At his adult life, he suggested that he is not bothered by any medical condition.

Surgical History: The patient suggested that he underwent a minor surgery at the age of 16 years for the removal of an appendix (Appendicitis). The patient reported that he has never been hospitalized with any medical condition, injuries, or accidents. The patient also suggested that he has never got a blood transfusion. Therefore, his overall health condition is typical.

Allergies: The patient reported that he was allergic to dust at his young life, but in his adult life he reports no allergy nor intolerance to drug, food, nor environment.

Medications: Ibuprofen (Advil).

Immunization: The patient reported that he is up to date with his immunizations and lastly, he reported that he got his flu, and yellow fever jabs in October.

Family History: The patient suggested that his paternal grandfather and grandmother are alive and healthy aged 92 and 86. His maternal grandfather deceased at the age of 80 due to chronic diabetes. He also suggested that his maternal grandfather died at the age of 60 in a road accident, but he was healthy. His parents are alive and healthy.

Social History: The patient is not married, but he lives in his apartment. He is sexually active and uses protection while copulating with his girlfriend. He is an intern at a finance company where he was recently employed. He is sober, though he takes wine occasionally. He is free from recreational drugs. He is a Christian and attends mass at the local church every Sunday.

OBJECTIVE DATA:

General: The patient is well groomed, nourished, alert and oriented, and logical in thought. His responses to queries are brief but logical.

Physical Exam: Temperature’s 101.2, Heart Rate: 121, Blood Pressure: 104/68, RR: 20, O2 sat; 99% on RA, Height: 155 lb, Weight: 5’7’, BMI: 25.2.

HEENT: Head; Normal cephalic and symmetric. The hair distribution and pattern are normal. Eyes; PERRLA, EOMI are conjunctiva pink, and no redness or drainage realized. Sees an optician every six months. Ears; External auditory canals were clear with no drainage. The tympanic membrane was pearly grey and intact with a good cone of light reflex bilaterally. Nose; The nasal turbinates are pink and moist, and he is free of nasal congestion. No discharge was noted, and was free of erythema and inflammations. Mouth and Throat; Oral mucosa is pink and moist with no lesions. The tongue midline is pink. The teeth were white and oriented with no bleeding gums.

Neck: The neck was supple with trachea midline. Tonsillar and anterior cervical lymphadenopathy and tenderness. The neck has no pain or stiffness.

Respiratory: The patients chest walls are symmetrical and his respiration is regular. The patient’s lungs are also clear to auscultation bilaterally.

Cardiovascular: The patient’s heart rate is normal and regular S1 & S2. No amble, strokes, or rumbles.

Gastrointestinal: The patients had no multitudes or hepatosplenomegaly. His bowel movements are normal in all the four quadrants of the abdomen. He was free of tenderness.

Genitourinary/ Gynaecological: The patient experienced a decreased appetite.

Musculoskeletal: The patient refuted joint stiffness, back pain, or dislocations.

Neurologic: The patient reports no seizures, paralyzes, syncope, or changes in memory.

Lymph/Heme: The patient refuted increased thirst or hunger, irregular temperatures, nor swollen glands.

Psychiatric: The patient reported no depression, sleeping challenges, anxiety, or mood disorientation.

Lab Tests

· Rapid Strep Tests – positive

· Centor score was applied while estimating the probability of acute streptococcal pharyngitis. The score was five suggesting streptococcal infection.

· Ant Streptolysin O (ASO) test to test for strep infections.

· Throat culture may also be done to test for strep viruses.

ASSESSMENT

Differential Diagnosis

Differential DX: Strep Pharyngitis (ICD-10-CM- J02.0) – Strep throat is a bacterial infection that can trigger a feeling of soreness or scratchy. If the disease goes untreated, it may result in kidney inflammation or rheumatic fever (Gold et al., 2020). This condition is most prevalent among children, but it can affect people of all ages (Gold et al., 2020). The condition’s signs and symptoms manifest in painful swallowing, fever, headaches, rash, nausea, or vomiting (Gold et al., 2020). The condition is caused by an infection by the bacterium Streptococcus pyogenes or group A streptococcus. The bacterium can be spread through saliva droplets, sneeze, or shared meals or drinks (Gold et al., 2020).

Differential DX: Infectious Mononucleosis (ICD-10-CM- B27.9) – Infectious Mononucleosis describes a group of symptoms that are usually caused by Epstein-Barr Virus (EBV), and it typically occurs in the teenagers, but does not have an age limit (Ishii et al., 2019). The virus is spread through saliva. However, when one gets the infection once, he cannot contract the condition again in life (Ishii et al., 2019). The condition manifests in the form of headaches, fatigue, muscle weakness, rash, night sweats, and swollen tonsils (Ishii et al., 2019). The differential was ruled out by the centor score of five and rapid strep test.

Differential DX: Influenza (ICD-10-CM- J11.1) – Influenza is a viral infection that negatively affects the respiratory system; the nose, throat, and lungs. The condition in most cases heals on its own, but its complications are severe (Hutchinson, 2018). The condition tends to be prevalent in people aged five years and below or above 65 years. It also affects persons with weak immune systems and Native Americans (Hutchinson, 2018). The symptoms of the condition are fever, chills and sweat, sore throat, eye pain, and runny nose or stuffy nose (Hutchinson, 2018). The differential will be ruled out by the tests done and the age limit of the patient.

Final Diagnoses

Differential DX: Strep Pharyngitis (ICD-10-CM- J02.0) – The patient will be diagnosed with Strep Pharyngitis as evidenced by the symptoms he had. The tests conducted also affirmed the tests.

Treatment Plan and Education

Differential DX: Strep Pharyngitis (ICD-10-CM- J02.0).

The condition can be treated by the use of antibiotics such as penicillin or amoxicillin. Therefore, the patient can take penicillin V 500 mg PO BID for 10 days or amoxicillin 500 mg PO BID for 10 days (Mustafa & Ghaffari, 2020).

Differential DX: Infectious Mononucleosis (ICD-10-CM- B27.9).

There are is no specific therapy for treating infectious mononucleosis since antibiotics do not function well against viral infections. The condition is managed through non-pharmacological approaches such as eating healthy diets and drinking plenty of fluids (Ishii et al., 2019).

Differential DX: Influenza (ICD-10-CM- J11.1).

The condition can be treated through the use of antiviral drugs such as Oseltamivir phosphate (Tamiflu) Peramivir (Rapivab) or Baloxavir (Xofluza). The patient can take Oseltamivir 75 mg two times a day for 5 days (Hutchinson, 2018).

Education

· The patient should be counselled to regular wash his hands.

· He should be counselled to cover his mouth when he coughs.

· He should also be counselled against sharing of personal items such as glasses and eating utensils.

References

Gold, J. A., Monnett, S. W., & Richmond, B. K. (2020). Peritonitis and Pyomyositis complicating strep pharyngitis. The American Surgeon, 000313482095149. 

https://doi.org/10.1177/0003134820951497

Hutchinson, E. C. (2018). Influenza virus. Trends in Microbiology, 26(9), 809-810. 

https://doi.org/10.1016/j.tim.2018.05.013

Ishii, T., Sasaki, Y., Maeda, T., Komatsu, F., Suzuki, T., & Urita, Y. (2019). Clinical differentiation of infectious mononucleosis that is caused by Epstein-Barr virus or cytomegalovirus: A single-center case-control study in Japan. Journal of Infection and Chemotherapy, 25(6), 431-436. 

https://doi.org/10.1016/j.jiac.2019.01.012

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