FNP 592 Week 4 SOAP Note: Clinical Documentation Template

• Week 4 Clinical Documentation Template

Order ready-to-submit essays - 100% plagiarism-free guaranteed!

Note: Our papers are 100% human-written. 

Student Name and clinical course:_____________(FNP 592)

Client’s Initials: XX

Age: 35

Race: American

Gender: Female

Date of Birth: January 1, 2000

Insurance: Yes  

Marital Status: Married

Subjective:

CC: “A week of difficulty in swallowing, sore throat, and fever.”

HPI: The patient presented herself to the clinic with a chief complaint of a persistent sore throat with fever, headache, and difficulty swallowing over the last seven days. She was a 35-year-old American female. She has looking-glass tonsils and enlarged cervical lymphadenopathy. The patient mentions that the level of pain in her throat is 7/10, which is worsened by fatigue and extreme temperatures. Although antibiotics alleviate the pain, it comes back within an hour. She does not report any neurological conditions or bowel dysfunction and does not have any recent travels or close contacts with ill people. Her present body temperature is 101 degrees.

Past Medical History:

• Medical problem list: Migraines until high school. The last three years, Sinusitis.
• Preventative care: Fully vaccinated. The last influenza vaccine was given in Jan 20
• Surgeries: None
• Last Pap: The pap smear was conducted two months ago, revealing no cervical abnormalities.
• Hospitalizations: None
• LMP: This occurred two weeks ago.

Allergies:

            Seasonal allergies. Sensitive to mold spores.

Medications:

• Advil 200mg, orally twice a day.
• Lozenges: spray twice a day.

Family History:

• Father, age 60, Hypertension.
• Mother, age 55, diagnosed with Type 2 diabetes and seasonal allergies.
• Sister, 25 years old, has migraine headaches.
• Paternal Grandmother, age 70, osteoporosis.
• Paternal Grandfather, age 72, has a history of gallstones.

Social History:

            The patient denies any history of tobacco or cigarette smoking and does not drink beer. My wife is a teacher. This is hiking and cooking as hobbies.

Other: N/A

ROS

General: No weight changes. Weakness, fatigue, and mild fever were reported.

Eyes: No vision changed, and no pain, redness, or excessive tearing; no double vision, blurred vision, or blindness.

Cardiovascular: Denies chest pain or palpitations.

Pulmonary: Productive cough, shortness of breath, wheezing, or pleuritic pain.

Neurological: Reports headache, dizziness, focal numbness/weakness, nausea, or vomiting.

Ears/Nose/Throat/Mouth: Sore throat and hoarse voice. Red, swollen tonsils were observed. Denies other ear or sinus symptoms.

Lymphatic: Swollen lymph nodes in the neck were present.

Allergy/Immunology: Seasonal or environmental allergies.

Objective

Vital Signs: 

HR-80

BP-120/80

Temp-101

RR-16

SpO2- 98%

Pain level- 7/10

Ht: 5 feet 4 in

Wt:158

BMI-24.2 (within normal range)

Labs, radiology, or other pertinent studies: Throat culture.

Physical Exam

General Appearance: Distress due to persistent throat pain.

Head: Reports severe headache or dizziness.

Eyes: No double or blurred vision.

ENT, Mouth: No hearing changes, earaches, or infection. Reports sore throat and a hoarse voice: no bleeding gums, dentures, a sore tongue, or a dry mouth. The last dental exam was five months ago.

Breast: Mammogram reports no abnormality.

Cardiovascular/Peripheral Vascular: Reports no chest pain or palpitations.

Musculoskeletal: No muscle weakness and denies limb tingling.

Integumentary: No blisters or scars on the skin are observed

Allergic/Immunologic: Seasonal or environmental allergies.

Other: N/A

Assessment

Differentials

1. Viral Pharyngitis is acquired due to viral infection, such as the common cold or the flu. The symptoms are a sore throat, the inability to swallow, and swollen tonsils (Orzell & Suryadevara, 2019). Nonetheless, pharyngitis caused by the virus generally resolves independently without the use of antibiotics.
2. Strep Throat: It is a disease that is caused by a bacterium known as Streptococcus pyogenes (Miller et al., 2022). Approximately, a sore throat, difficulty in swallowing, swollen tonsils, fever, and occasionally white spots on the tonsils are some of the possible symptoms of strep throat.
3. Tonsillitis: Tonsillitis is the inflammation of the tonsils, which can happen as a result of viral or bacterial infection. Strep throat is a kind of bacterial tonsillitis, although other forms of tonsillitis can be caused by a virus (Norton and Myers, 2021). Tonsillitis may present symptoms that are similar to strep throat, such as sore throat, swollen tonsils, and difficulty swallowing.

Diagnosis: Strep Throat

Plan 

Diagnostics:  Involved a comprehensive evaluation of the medical history, including physical examination of the throat and the lymph nodes. Lab tests like rapid strep or throat cultures were done to prove the presence of streptococcal bacteria.

Treatment: The treatment of strep throat is aimed at relieving the symptoms and eliminating the bacterial infection by using antibiotics, penicillin 250 mg orally (4 times per day), and amoxicillin 500mg (3 times per day). The first category of symptomatic treatment I would recommend consists of over-the-counter pain medications, throat lozenges, and warm salt water gargles (Tomić and Pecikoza, 2022). Enough rest and hydration are also prescribed.

Education: Inform the patient about the nature of strep throat, its causes, symptoms, and ways of being treated. Patients must be educated on the importance of taking all the rounds of antibiotics to avoid complications, as well as to be less likely to transmit it to others. Also, the information about the infection transmission prevention (hand hygiene and contactless communication with others) should be given.

Follow-up: The strep throat normally ends after a week of proper treatment, but a follow-up is required to confirm that there is full recovery and to check whether there are complications. The patient is to be advised to contact their medical professional in case of the persistence or aggravation of the symptoms despite treatment or because of the appearance of new symptoms that include the inability to breathe or swallow.

For the week 2 of class visit: FNP 592 Week 2 SOAP Notes