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Episodic/Focused SOAP Note
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Patient Information: Lily, 20-year-old, Female S. CC: “Sore throat” HPI: The patient is a 20-year-old female who developed a sore throat 3 days ago Location: Throat Onset: 3 days ago Character: sore Associated signs and symptoms: decreased appetite, headache and pain with swallowing Timing: Would ask Exacerbating/ relieving factors: Would ask Severity: Would ask Current Medications: Unknown Allergies: Unknown PMHx: Unknown Soc Hx: Student at the local college. Fam Hx: Unknown ROS: HEENT: Eyes: Ears, nose and throat: Negative for congestion. Positive for runny nose and sore throat, pain with swallowing. GASTROINTESTINAL: Positive for decreased appetite NEUROLOGICAL: Positive for headache O. HEENT: Eyes: Ears, nose and throat: Patient has runny nose, does not sound congested. Patient has slight hoarseness in voice. Diagnostic results: Full vital signs – to include temperature Through mouth and throat exam – specifically looking for puss or enlarged tonsils Rapid influenza test – One study tested 3782 subjects that presented with a fever greater than 38degrees Celsius and either a cough or sore throat. Of these subjects the influenza PCR tested positive 33% of the time and negative 67% of the time. This study showed that the influenza PCR is better at ruling out influenza (Anderson et al., 2018). Monospot test A. Differential Diagnoses Airway Reflux: Acid reflux and sometimes reach higher areas up into the throat. This can create a sore throat and typically leads to a hoarse voice (Adams, 2017). Other symptoms to address include a feeling of a lump in the throat and waking up at night gasping for air (Adams, 2017). Upper Respiratory Infection: Viral upper respiratory infections can create vocal cord inflammation which could be why Lily has a hoarse voice (Dains, Baumann & Scheibel, 2016, p. 9714). Pharyngitis: Bacterial infections can lead to a sore throat and a headache (Dains, Baumann & Scheibel, 2016, p. 9137). Epiglottitis: An infection with H influenza type B, typically presents with sore throat and pain while swallowing (Dains, Baumann & Scheibel, 2016, p. 14434). Mononucleosis: Typically presents with a gradual onset, mild sore throat, malaise and fatigue (Dains, Baumann & Scheibel, 2016, p. 14459). P. References Adams, J. U. (2017). Sore throat and hoarseness might not be just a cold. The Washington Post. Anderson, K. B., Simasathien, S., Watanaveeradej, V., Weg, A. L., Ellison, D. W., Suwanpakdee, D., & Jarman, R. G. (2018). Clinical and laboratory predictors of influenza infection among individuals with influenza-like illness presenting to an urban Thai hospital over a five-year period. Plos ONE, 13(3), 1. doi:10.1371/journal.pone.0193050 Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Episodic/Focused SOAP Note Template
J, 11, Male, XX (Race)
CC: “Mild ear ache”
HPI: The patient is 11 year old XX male who presented himself with a mild right ear ache, which started two days ago. Associated symptom include possible fever, right ear pain, difficulty hearing from the right ear. Associated symptom are exacerbated with sleep.
Current Medications: Inquire if patient is currently taking any medications, rule out earring loss related to medication toxicity.
Allergies: Inquire about allergies.
PMH: Inquire if patient has a history of acute otitis media or underlying hearing loss. Inquire if patient has had tonsillectomy or an adenoidectomy in the past.
SH: Spends time in pool during summer.
FH: Inquire if family members have history of hearing loss.
- GENERAL: Possible fever. Inquire about patient’s swimming habits and ask if ear plugs used. Determine method of cleaning ear.
- HEENT: Right ear pain. Inquire if patient has tinnitus, discharge from ear, vertigo, or itchiness. Inquire if patient has a history of acute otitis media, hearing loss, vertigo, tinnitus, discharge from ear canal.
- RESPIRATORY: Inquire if patient has had post nasal discharge or sputum production and ask about color of mucous.
- ALLERGIES: Unknown
- HEENT— Assess outer ear and note surrounding tissue, shape, color, and any lesions. Assess the external ear for discharge or any odor. Assess for the placement of a foreign object in ear. Assess for tenderness on the outer ear near the auricle and mastoid. Tenderness could indicate a possible infection. Use otoscope to assess external and middle ear. At this time, assess for erythema, lesions, and discharge. Inspect tympanic membrane for perforations. Assess the frontal and maxillary sinuses for swelling. No tenderness or swelling over the soft tissue should be present. Assess tonsils and inside of mouth for lesions, erythema, and swelling.
- RESPIRATORY: Determine if upper respiratory infection is present, assess for clear lungs.
- Whispered Voice- Determines if patient is able to hear whispering. If they do not pass this test, hearing loss could be assumed. (Ball, Dains, Flynn, Solomon, Stewart, et al., 2015, p. 241).
- Weber Test- Determines unilateral hearing loss (Ball et al., 2015, p. 241).
- Rinne Test- Determines if the patient conducts sound better through bone or air. The patient should hear the sound conducted through the air twice as long (Ball et al., 2015, p. 241)
- Culture of ear fluid (Attlmayr, 2015).
- Otitis externa
- Often seen with individuals that swim. This infection is located on the outer ear. Pain is worse when an otoscope is inserted because sensitivity is on the outer ear. The outer portion of the ear is often inlamted and tender to touch. When inspecting the ear, the ear canal would appear narrow. Because of the narrowing, fluid is unable to drain from the ear (Rosenfeld et al., 2014).
- Otitis media
- Otitis media is a middle ear infection that usually presents unilaterally, hearing loss is present, and tympanic membrane is pink. Pus often forms inside the ear, which could cause perforation of the tympanic membrane. Ear pain, fever, difficulty hearing, irritability, and lethargy can also accompany this diagnosis. While examining the ear with the otoscope, erythema, dullness, decrease light reflex, and bulging of the tympanic membrane (Nash, 2013).
- Eustachian catarrh
- Often results after an upper respiratory infection. It would be essential to determine if the patient has has a recent upper respiratory tract infection. Fluid collects in the eustachian tube, which causes pain and trouble hearing (Nash, 2013).
- The growth of a skin tag inside the ear, behind the ear drum. The patient could be born with it or it can develop after several ear infections. It would be essential to determine if the patient has had frequent ear infections in the past (Chawla, Ezhil Bosco, Lim, Shenoy, & Krishnan, 2015).
- Mastoiditis is a common complication of acute otitis media. Pain, erythema, and tenderness are typically present alone the mastoid process (Attlmayr, 2015).
Attlmayr, B., Zaman, S., Scott, J., Derbyshire, S. G., Clarke, R. W., & De, S. (2015).
Paediatric acute mastoiditis, then and now: Is it more of a problem now?. The Journal
Of Laryngology And Otology, 129(10), 955-959. doi:10.1017/S0022215115002078
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.
Chawla, A., Ezhil Bosco, J. I., Lim, T. C., Shenoy, J. N., & Krishnan, V. (2015). Computed tomography
features of external auditory canal cholesteatoma: A pictorial review. Current Problems In
Diagnostic Radiology, 44(6), 511-516. doi:10.1067/j.cpradiol.2015.05.001
Nash, L. (2013). A case study on prescribing for an acute ear infection in a child. Nurse Prescribing,
Rosenfeld, R. M., Schwartz, S. R., Cannon, C. R., Roland, P. S., Simon, G. R., Kumar, K. A., & …
Robertson, P. J. (2014). Clinical practice guideline: Acute otitis externa. Otolaryngology-Head &
Neck Surgery, 150S1-S24. doi:10.1177/0194599813517083