Focused throat exam

Comprehensive SOAP Template

Patient Initials: ____L. W___ Age: ___20____ Gender: ____Female ___

O = onset of symptom: Gradual

L= Throat

D= recent

C= normal moods according to the setting

A= flu-like symptoms such as a sore throat, appetite, headaches, and pain in swallowing, runny nose and a slight hoarseness in her voice

R= taken pain killers and throat clearing mint tablet

S= not severe

SUBJECTIVE DATA:

Chief Complaint (CC): the 20-year-old female lady presents to the Primacy Care Provider complaining of a sore throat that has lasted for three days, the condition also comes with flu-like symptoms a day sore throat, appetite, headaches, and pain in swallowing, runny nose and a slight hoarseness in her voice. The PCP carry out clinical observations such as ordering for a diagnostic test, examinations of the patient and

History of Present Illness (HPI):

Medications: Over-the-counter vitamin, and herbal supplements one tablet each every day.

Allergies: no history of allergies. Patient reports to have a history of high blood pressure and fluctuating weight gain such as 14 pounds since last year.

Past Medical History (PMH): childhood illness was atopic eczema, but it cleared when she was six years of age.

Past Surgical History (PSH): she had a left leg surgery after falling from a tree when she was 13 years.

Sexual/Reproductive History: If applicable, Normal none complicated menstruation. The patient reports that she does not engage in risky sexual actions.

Personal/Social History: patient reports not to take drugs, tobacco or alcohol due to her religious faith. She does not engage in sports gymnastics and active games such as athletics and basketball. She does not watch weight and eats snacks and fast foods.

Immunization History: last year she received Tdap but has no immunization for pneumonia and flu.

Significant Family History: Father is obese and suffers from type 2 diabetes. Mother is active, healthy and with normal weight. Her siblings are healthy, and she is the only one who is overweight. She has no children.

Lifestyle: Patiently is from a well-off family. She has a stable boyfriend, believes in Christianity and has family and economic support

Review of Systems:

General: recent witnessed weight changes, fatigue, weakness or fever,

HEENT: no Normocephalic and nontraumatic (Ball, et al., 2015).

Neck: presence of the jugular vein and lymphadenopathy and thyromegaly

Breasts: standard

Respiratory: presence of rub and murmur on chests and unclear auscultation bilaterally in upper and lower lobes

Cardiovascular/Peripheral Vascular: lack of pedal edema

Gastrointestinal: regular bowel movement

Genitourinary: no pain while urinating

Musculoskeletal: no pain and full motion

Psychiatric: alert and oriented

Neurological: oriented

Skin: normal

Hematologic: none

Endocrine: normal

Allergic/Immunologic: none

OBJECTIVE DATA:

Physical Exam:

Vital signs: I temperature 96. O F, Height 65 inches. Weight 180lbs, BMI, 25.8, heart rate 73. Blood pressure 156/72

General: upright posture, gait. She is a well-groomed lady appropriately dressed for the weather. She looks sad and pale. Lack of body odors or bad smell

Neck: painful in motion and swallowing

Chest: murmur of the chest

Lungs: presence of auscultation bilaterally

Heart: 73 heart beat

Peripheral Vascular: Abdomen:

Genital/Rectal: Deferred Musculoskeletal: no pain, full motion

Neurological: alert and oriented

Skin: soft and smooth

ASSESSMENT:

Priority dx: Pharyngitis it is a condition caused by the virus. It causes cold-like symptoms and throat pain.

Alternative conditions

1. Mononucleosis. It is a condition that causes a sore throat, extreme fatigue, and muscle ache. No muscle ache reported
2. Acute sinusitis: acute sinusitis causes sinuses inflammation. Symptoms are facial redness, sinus tenderness and pain. No sinuses reported.
3. Mumps: Mumps is a viral disease that is highly contagious and causes swelling of saliva glands. No swelling.
4. Strep throat. It is a condition causing the sore throat with white patches. No patches.
5. A tension headache. It is a muscle tension condition causing headaches, pressure, pain and tightness around the head. No tightness reported.
6. Tonsillitis. Painful tonsils were swelling causing painful tonsils, painful throat m fever and pain. No red tonsils visible
7. Laryngitis is a condition of larynx inflammation. Lack of voice and hoarseness of voice. No loss in voice.
8. Aseptic Meningitis causes neck pain, headache, fever, nausea. Nor neck pain
9. Common cold: viral respiratory condition was causing sore throat, headache, runny nose and stuffiness. No stuffy nose
10. Chronic sinusitis causes runny and stuffy nose, sore throat, tooth pain. No tooth pain (Sullivan, 2012)

PLAN:

Treatment Plan: take anti-inflammatory medications and drugs like acetaminophen for fever control. Relieve symptoms by gargling warm salty water several times during the day (Seidel, et al., 2011).

Health Promotion: Include exercise, and diet, and inform family on the importance of healthy diet and exercises. Drink plenty of fluids to keep hydrated. Gargle warm salt water, eat warm broth. Bed rest and use a humidifier. Throat lozenges can help in soothing pain

Disease Prevention:

Avoid sharing utensils, food, and drinks. Avoid other sick people. Wash hands after sneezing and coughing and before eating. Avoid second-hand smoking and smoking.

REFLECTION:

From this experience, I learn that numerous conditions cause sore throat. It is important to be keen to rule out symptoms that the client is not experiencing to establish the right diagnosis. Understanding and knowing all the above-related conditions is crucial in my medical practice. I will research more on the unique characteristics of each condition to be sure that I am diagnosing the right disease. I agree with evidence from studies on the crucial aspects of assessment (Dains, Baumann, &Scheibel, 2016).

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J., Baumann, L, &Scheibel, P.(2016) Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for head, face, and neck. In Mosby's guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.

Sherry Roberts is the author of this paper. A senior editor at Melda Research in custom college essay services if you need a similar paper you can place your order for a custom research paper from legitimate paper writing services.

"Janet Peter is the Managing Director of a globally competitive essay writing company.