SOAP Note Herpangina

SOAP Note Template

Chief Complaint: My head is aching and I have problems swallowing and feeding.

Patient Initials: RG Gender: M/F/Transgender

Age: 11 years

Race: Black

Ethnicity: African American

Reason for Seeking Health Care: The client visits the facility complaining about fever, sore throat, and headache.

HPI: RG is brought to the clinic because he is experiencing fever, soreness in the throat, and a headache. He locates the pain in the head and throat. He rates the pain at 7 out of 10 and describes it as sore, burning, and achy. According to RG, the pain began yesterday and has been constant. He feels the pain all the time but becomes worse whenever he sips a cold or warm liquid. He also reports that the pain intensifies when he takes tepid baths. RG is also displaying symptoms of swollen glands, difficulties in swallowing, and throat redness.

Allergies: Pollen and dust.
Current perception of Health: Excellent Good Fair Poor

Past Medical History

• Major/Chronic Illnesses: No history of chronic illness.
• Trauma/Injury: No history of trauma or injury
• Hospitalizations: No recent hospitalizations.

Past Surgical History: No history of surgical procedure.

Medications: Ibuprofen and Pushing flds.

Family History: The paternal grandmother of RG died as a result of type 2 diabetes. His paternal grandfather is alive and aged 56 years. He suffers from arthritis in the last 3 years. The maternal grandfather is alive and suffers from hypertension, while the maternal grandmother has no chronic illness. RG’s mother does not suffer from a chronic illness. His father also does not suffer from a major illness. RG has one sibling who is also in good health.

Social history:

RG lives in a single house. He is unemployed because he is a minor. He is not exposed to smoking or recreational drugs. Sexual orientation and activity are none applicable in the case of RG because of his age. Furthermore, RG is yet to attain the age for contraceptive use. The family of RG is composed of father, mother, and siblings. He easily interacts with family members and peers at home and school.

Health Maintenance

Screening Tests: RG has not undergone screening tests like PSA, colonoscopy, and mammogram.

Exposures: No exposures

Immunization HX: Polio, influenza, diphtheria, chickenpox, and measles.

Review of Systems:

General: Reports fever, sore throat, headache, and chills. His mother denies RG losing weight unintentionally or experiencing weight gain. RG denies experiencing a decline in appetite.

Neck: Reports swelling in glands and neck pain whenever he turns.

Lungs: Clear to percussion and auscultation.

Cardiovascular: Denies pain in the chest, swelling, or hypertension.

Breast: N/A

GI: Reports appetite loss and denies diarrhea, vomiting and nausea.

Male/female genital: N/A

GU: Inactive sexually, denies dysuria, and denies history of kidney stone.

Neuro: Denies sensation abnormalities and pain on touch. Reports normal reflexes and upper and lower extremity function.

Musculoskeletal: No back pain, reports that he is physically active, and denies joint pain.

Activity & Exercise: Reports to be physically active. Says that he plays football and other games.

Psychosocial: Denies changes in mood, anxiety, and depression.

Derm: Reports no rashes and lesions. Denies having cracks.

Nutrition: Agrees to have less appetite.

Sleep/Rest: Reports sleep difficulties due to pain in throat.

LMP: N/A

STI Hx: No STI infection history.

Physical Exam

BP__110/64______TPR_102.2____ HR: _74 bpm_RR: _16 bpm___Ht. _53.6 inches____ Wt. __74 lbs___ BMI (percentile) _99%

General: Well groomed, slightly distressed, and well nourished.

Neck: Neck is supple, thyroid is normal, limited movement.

Pulmonary: Lung sounds are clear.

Cardiovascular: Apical pulse-98 per minute, normal heart rhythm and rate, no murmur. Normal S1 and S2.

Breast: N/A

GI: No abdominal hernia or mass. No abdominal tenderness.

Male/female genital: Not conducted.

GU: Systems are intact and normal.

Neuro: No atrophy or tremors. Using normal gait.

Musculoskeletal: No signs of joint pain, no somatic dysfunction, no joint or muscle swelling.

Derm: Good turgor, No bruises, lesions, or rashes.

Psychosocial: Alert and oriented. Small signs of distress.

Misc. N/A

Significant Data/Contributing Dx/Labs/Misc.

Rapid Strep test - Negative

Plan:

Differential Diagnoses

1. Viral pharyngitis- This disease is a possibility because the patient exhibits symptoms such as sore throat, high fever, and swollen tonsils. Viral pharyngitis patients also present white ulcerations on the soft palate as it is in this patient (Yu et al., 2020).
2. Streptococcal pharyngitis- The patient might be suffering from this disease because he has high fever, painful swallowing, swollen tonsils, and red spots in the soft palate (Yu et al., 2020).
3. Mononucleosis- This disease is a possibility because the patient has high fever, sore throat, headache, swollen lymph nodes and tonsils (Apriasari & Utami, 2020). However, he does not have swollen spleen or skin rash.

Principal Diagnosis: Herpangina.

Plan

Diagnosis: Herpangina

Diagnostic Testing: The patient underwent physical testing and complete history.

Pharmacological Treatment: The patient will take Acetaminophen and Ibuprofen PRN, Benadryl and ½ tsp. He will also need regular hydration.

Education: The patient and the mother will be informed to ensure regular hydration and rest. The patient was directed to report immediately if symptoms persist or worsen. Patient education also provided information about herpangina.

Referrals: None

Follow-up: After one week.

Anticipatory Guidance: The patient needs to adhere to medication prescription. The patient and the mother were informed that the infection will clear within few days.