Soap note for strep throat

Name: V.S

Date:04/23/2018

Sex: Male

Age/DOB/Place of Birth: 9 years old/09/04/2008/Cuba

SUBJECTIVE

Historian: Patient and her mother

Present Concerns/CC: “My throat is being hurting for the last 3 days and I start having fever since last night”

Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx)

9 years old male A+ student. He has met all his milestone timely. He actively engaged in sports, currently playing basketball in the school team. He likes to eat fast food but his mother reports that he tried to reinforce him to eat balanced meals including fruits and vegetables every day as well as maintaining an adequate hydration status throughout the day by drinking water and Gatorade while practice basketball. Patient sleeps an estimate of 8 to 9 hours at night. Denies problems falling or staying asleep. No indications of bullying at school. He wears seatbelt always. Mother reports smoke alarm at home denies guns possession at home.

HPI: (must include all components)

Patient with no significant PMH. Presented to the clinic c/o cough, sore throat for 3 days and fever since last night. He stated when he swallows, the pain is worse and only feels some relief with cold drinks. Mother stated that his max Temp was 1011. last night and she gave him Ibuprofen OTC for the fever. Pain is described as feeling a raw throat.

Medications: (List with reason for med)

Ibuprofen OTC 12.5 ml every 4 hours as needed for fever.

PMHX:

Allergies: NKA

Medication Intolerances: None

Chronic Illnesses/ traumas: none

Hospitalizations/Surgeries: one

Immunizations: All immunizations up to date, except for FLU vaccine for this year.

Family History ( Please identify all immediate family)

Mother and father are alive and healthy.

Maternal grandfather died at 60 years old from a car accident. Maternal grandmother alive suffering from generalized OA.

Paternal Grandfather alive suffering from BPH and TIA. Paternal Grandmother alive suffering from HTN.

Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status

Patient is only child who lives with his parents in peaceful house environment. He is described by his mother as an excellent son and student always willing to help in the house. Both parents are professionals who work full time. Patient can watch TV for 1 hours a day. Mother denies exposure to alcohol, drugs, or smoking. Safety at home with smoke and CO2 detectors, alarm, and cameras.

ROS

General

Denies malaise, weakness, or night sweats. Positive for fever up to 101 F and decreased appetite

Cardiovascular

Denies chest pain, heart murmurs or leg swelling

Skin

Denis petechiae, bruises, wounds, or ecchymosis

Respiratory

Report cough. Denies hemoptysis, difficulty breathing or SOB

Eyes

Denies eye pain, discharge, or visual problems

Gastrointestinal

Denies nausea, vomiting, constipation, or diarrhea, pyrosis, or epigastric pain. Report anorexia

Ears

Report ear pressure. Denies vertigo or tinnitus

Genitourinary/Gynecological

Denies cloudy urine, urgency, or incontinence

Nose/Mouth/Throat

Report sore throat and difficulty swallowing. Denies for hoarseness, nasal congestion, or nose bleeds

Musculoskeletal

Denies joint pain or stiffness

Breast

Not assessed

Neurological

Denies headaches, numbness, tingling or syncope

Heme/Lymph/Endo

Denies fatigue, anemia, cold/heat intolerance or enlarged lymph nodes

Psychiatric

Denies depression, insomnia, or nightmares

OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart

Weight

80 lbs (59th percentile)

Temp

99.1

BP

107/65

Height

4’10” (19th percentile)

Pulse

76

Resp

18

General Appearance and parent‐child interaction:

Healthy appearing child in NAD with normal ambulation and interaction with mother and healthcare provider

Skin

Skin is warm, dry, clean, and intact. No rashes or lesions noted.

HEENT

Head is non-traumatic. EOMs intact. Pupils PERRLA. Neck is supple without JVD. Tympanic membranes clear of fluid without redness. Nose with patent nares and midline septum. Throat is very erythematous with inflamed uvula, tonsils, and pharynx. No lesions or exudates present. Neck supple with full ROM.

Cardiovascular

Normal heart rate and sounds. Pedal pulses 2+ bilaterally. No cyanosis, clubbing or edema of the lower extremities

Respiratory

Breathing effort within normal limits. Lungs clear to auscultation bilaterally

Gastrointestinal

Bowel sounds active x 4 quadrants. No rigidity or guarding.

Breast

Not assessed

Genitourinary

No bladder distention or CVA tenderness

Musculoskeletal

Erect posture. Stable joints without pain or tenderness to palpation

Neurological

Speech clear. Balance stable; gait normal.

Psychiatric

Normal mood, affect and interaction. AAO x3. No signs of suicidal intentions

In-house Lab Tests – document tests (results or pending)

Rapid strep throat group A: positive

Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale

For adolescents (HEADSSSVG Assessment)

HEADSSSVG was conducted and no evidence of depression was found. Patient lives with parents at home. Reports having a happy life. No concerns currently.

Diagnosis

. Differential diagnosis-

. Streptococcal pharyngitis (J02.0): According to the Columbian Electronic Encyclopedia (2017), this condition mainly occurs in children and typical signs and symptoms include fever and sore throat

. Acute tonsillitis (J03.90): Tonsillitis is an inflammation of the tonsils. It can be caused by viral or bacterial infections (Gahleitner et al., 2016). It typically causes throat pain, difficulty swallowing and loss of voice.

. Viral pharyngitis (J02.9): When no bacteria is found, it’s referred as viral pharyngitis. This can cause all the same symptoms including sore throat, dysphagia, fever and redness

Primary Diagnosis:

. J02.0: Streptococcal pharyngitis

.

Plan including education

· Bicillin L-A 1,200,000 units/2ml per syringe. Administer 1.2ml IM in the office. This is indicated for treatment of Group A streptococcal infection (Columbia Electronic Encyclopedia, 2017).

· F/U in the office in 72 hours if no improvement

Education

· Call 911 if patient developed symptoms of difficulty breathing, lip cyanosis or inability to open the mouth. This can be indicative of serious life-threatening condition or allergic reaction and emergent treatment is needed.

· Increase fluid intake. This will help fight the fever the infection while preventing dehydration

· Use cold compresses to decrease fever.

· Use light clothing when fever is high to allow the body to cool down

· Wait 24 hours before returning to school

· Call office if symptoms do not improve within 48 hours.

References:

Gahleitner, C., Hofauer, B., Stark, T., & Knopf, A. (2016). Predisposing factors and management of

complications in acute tonsillitis. Acta Oto-Laryngologica, 136(9), 964-968.

doi:10.3109/00016489.2016.1170202

Sore throat, streptococcal. (2017). Columbia Electronic Encyclopedia, 6th Edition, 1.

*ALL references must be Evidence Based (EB)