(SOAP NOTE) NR511 MARY 40 YO
FEMALE CAUCASIAN (CC Sore Throat)
Patient Information: Mary, 40 yr old F, Caucasian
S:
CC: Sore Throat
HPI: Patient c/o sore throat that began yesterday and is worse when she swallows. She states
she has not eaten or drank anything because it hurts too much. She states it feels like something
sharp is in her throat when she swallows. Patient also reports a new onset of fatigue and chills.
Patient is currently not taking anything for the pain. She reports the pain 4/5 when swallowing.
Current Medications: Daily multivitamin, B complex supplement.
Allergies: NKDA.
m
er as
PMHx: Denies any past illness, injuries or surgeries. Hospitalized x2 for childbirth.
co
eH w
Soc Hx: Married, drinks alcohol socially, denies tobacco or illicit drug use.
o.
Fam Hx: Mary lives with her husband, her parents and her 4 children. Her father and husband
rs e
both smoke but she states they do not smoke "in the house". Mary also states they have 2 dogs
ou urc
and a cat.
ROS:
o
aC s
Constitutional: Denies weight loss. Reports new onset of fatigue and chills.
vi y re
HEENT: Denies any headaches and visual changes, wears contact lenses. No reported hearing
loss, or ringing in the ears. No reported nasal congestion or discharge. Reports sore throat and
difficulty swallowing, denies cough and hoarseness.
ed d
ar stu
Cardiovascular: Denies chest pain, palpitations and dizziness.
Respiratory: Denies cough, difficulty breathing, and shortness of breath or wheezing.
is
Gastrointestinal: No reported bowel problems. No heartburn or indigestion reported.
Th
Lymphatics: Denies any enlarged lymph nodes.
sh
O:
Vital signs: BP 128/72, Temp 101.2, P 100, RR 14 Height: 5' 4" Weight: 149 BMI:
25.6 (overweight)
General: Alert, orientated, and cooperative.
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, HEENT: Head: Normocephalic. Hair thick and distribution throughout scalp. Eyes: without
exudate, sclera clear. Contact lenses noted. Ears: Tympanic membranes gray and intact with cone
of light noted. Pinna and tragus non-tender. Nose: Nares patent without exudate. Throat:
Oropharynx moist with erythema with white exudate noted. Tonsils 3/4 bilaterally. Teeth in
good repair, no cavities noted. Neck supple. Thyroid midline, small and firm without palpable
masses.
Cardiovascular: S1 S2 noted, no murmurs, palpitations, chest pain or discomfort noted.
Tachycardia.
Respiratory: Respirations even and unlabored, no distress noted. Lung sounds CTA all anterior
and posterior lung fields bilaterally. No SOB, wheezing, or cough observed.
Gastrointestinal: Abdomen soft, non-tender, bowel sounds present all four quadrants. No
organomegaly noted.
Lymphatics: Anterior cervical lymph tender to palpation. No lymphadenopathy.
m
er as
Diagnostic results: Rapid strep test positive.
co
eH w
A:
o.
Streptococcal Pharyngitis (ICD-10 J02.0): Infectious inflammation of the pharynx and the
rs e
pharyngeal tonsils, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Pharyngitis and
ou urc
tonsillitis usually occur at the same time and these two diseases are contagious. This is caused by
the Group A beta-hemolytic streptococcal infection, which is caused by group A Streptococcus.
This can cause scarlet fever or autoimmune rheumatic fever it not treated with
o
antibiotics, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). People diagnosed with this
aC s
illness must have 2-3 of the following symptoms and if they do the Rapid strep test is performed
vi y re
and antibiotic therapy started symptoms include fever greater than 100.5, tonsillar exudate,
tender anterior cervical lymphadenopathy, and no cough (Dunphy, Winland-Brown, Porter, &
Thomas, 2015). Mary presents with all these symptoms.
ed d
P:
ar stu
Medications:
is
Rx: Amoxicillin
Th
Amoxicillin 500 mg capsules
Sig: 1 cap PO BID Disp #20 (twenty), No refills (Epocrates, 2017).
sh
Rx: Acetaminophen
Acetaminophen 325 mg 2 tabs PO every 4-6 hours as needed for pain or fever, (Dunphy,
Winland-Brown, Porter, & Thomas, 2015).
Nonprescription throat lozenges as needed for pain, (Dunphy, Winland-Brown, Porter, &
This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:16:52 GMT -05:00
https://www.coursehero.com/file/26181319/NR511-week-2-discussion-2docx/
FEMALE CAUCASIAN (CC Sore Throat)
Patient Information: Mary, 40 yr old F, Caucasian
S:
CC: Sore Throat
HPI: Patient c/o sore throat that began yesterday and is worse when she swallows. She states
she has not eaten or drank anything because it hurts too much. She states it feels like something
sharp is in her throat when she swallows. Patient also reports a new onset of fatigue and chills.
Patient is currently not taking anything for the pain. She reports the pain 4/5 when swallowing.
Current Medications: Daily multivitamin, B complex supplement.
Allergies: NKDA.
m
er as
PMHx: Denies any past illness, injuries or surgeries. Hospitalized x2 for childbirth.
co
eH w
Soc Hx: Married, drinks alcohol socially, denies tobacco or illicit drug use.
o.
Fam Hx: Mary lives with her husband, her parents and her 4 children. Her father and husband
rs e
both smoke but she states they do not smoke "in the house". Mary also states they have 2 dogs
ou urc
and a cat.
ROS:
o
aC s
Constitutional: Denies weight loss. Reports new onset of fatigue and chills.
vi y re
HEENT: Denies any headaches and visual changes, wears contact lenses. No reported hearing
loss, or ringing in the ears. No reported nasal congestion or discharge. Reports sore throat and
difficulty swallowing, denies cough and hoarseness.
ed d
ar stu
Cardiovascular: Denies chest pain, palpitations and dizziness.
Respiratory: Denies cough, difficulty breathing, and shortness of breath or wheezing.
is
Gastrointestinal: No reported bowel problems. No heartburn or indigestion reported.
Th
Lymphatics: Denies any enlarged lymph nodes.
sh
O:
Vital signs: BP 128/72, Temp 101.2, P 100, RR 14 Height: 5' 4" Weight: 149 BMI:
25.6 (overweight)
General: Alert, orientated, and cooperative.
This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:16:52 GMT -05:00
https://www.coursehero.com/file/26181319/NR511-week-2-discussion-2docx/
, HEENT: Head: Normocephalic. Hair thick and distribution throughout scalp. Eyes: without
exudate, sclera clear. Contact lenses noted. Ears: Tympanic membranes gray and intact with cone
of light noted. Pinna and tragus non-tender. Nose: Nares patent without exudate. Throat:
Oropharynx moist with erythema with white exudate noted. Tonsils 3/4 bilaterally. Teeth in
good repair, no cavities noted. Neck supple. Thyroid midline, small and firm without palpable
masses.
Cardiovascular: S1 S2 noted, no murmurs, palpitations, chest pain or discomfort noted.
Tachycardia.
Respiratory: Respirations even and unlabored, no distress noted. Lung sounds CTA all anterior
and posterior lung fields bilaterally. No SOB, wheezing, or cough observed.
Gastrointestinal: Abdomen soft, non-tender, bowel sounds present all four quadrants. No
organomegaly noted.
Lymphatics: Anterior cervical lymph tender to palpation. No lymphadenopathy.
m
er as
Diagnostic results: Rapid strep test positive.
co
eH w
A:
o.
Streptococcal Pharyngitis (ICD-10 J02.0): Infectious inflammation of the pharynx and the
rs e
pharyngeal tonsils, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Pharyngitis and
ou urc
tonsillitis usually occur at the same time and these two diseases are contagious. This is caused by
the Group A beta-hemolytic streptococcal infection, which is caused by group A Streptococcus.
This can cause scarlet fever or autoimmune rheumatic fever it not treated with
o
antibiotics, (Dunphy, Winland-Brown, Porter, & Thomas, 2015). People diagnosed with this
aC s
illness must have 2-3 of the following symptoms and if they do the Rapid strep test is performed
vi y re
and antibiotic therapy started symptoms include fever greater than 100.5, tonsillar exudate,
tender anterior cervical lymphadenopathy, and no cough (Dunphy, Winland-Brown, Porter, &
Thomas, 2015). Mary presents with all these symptoms.
ed d
P:
ar stu
Medications:
is
Rx: Amoxicillin
Th
Amoxicillin 500 mg capsules
Sig: 1 cap PO BID Disp #20 (twenty), No refills (Epocrates, 2017).
sh
Rx: Acetaminophen
Acetaminophen 325 mg 2 tabs PO every 4-6 hours as needed for pain or fever, (Dunphy,
Winland-Brown, Porter, & Thomas, 2015).
Nonprescription throat lozenges as needed for pain, (Dunphy, Winland-Brown, Porter, &
This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:16:52 GMT -05:00
https://www.coursehero.com/file/26181319/NR511-week-2-discussion-2docx/
