Soap Note Week Three: Acute Pharyngitis Student U.S.

Soap Note Week Three: Acute Pharyngitis Student United States University FNP592

Identify the core assignment prompt and restructure the content to focus solely on the task: writing an academic SOAP note on acute pharyngitis based on provided sample notes and guidelines.

Paper For Above instruction

The task is to compose an academic SOAP (Subjective, Objective, Assessment, Plan) note focusing on a case of acute pharyngitis, structured clearly and professionally, using the provided sample notes and guidelines. This involves creating a comprehensive clinical documentation of a patient presenting with sore throat, neck pain, and difficulty swallowing, integrating relevant patient history, physical examination findings, differential diagnoses, and management plan, supported by credible references. The note should simulate real-world clinical practice, demonstrating proficiency in assessment and evidence-based decision-making.

Introduction

Acute pharyngitis is a common condition encountered in primary care settings, characterized primarily by inflammation of the pharyngeal mucosa. It often manifests with sore throat and difficulty swallowing, posing diagnostic challenges in distinguishing viral from bacterial etiologies. Proper assessment, including detailed patient history, physical examination, and appropriate diagnostic testing, is essential for effective management. This paper aims to develop a comprehensive SOAP note based on a typical presentation of acute pharyngitis, applying clinical reasoning and evidence-based guidelines.

Subjective Findings

The patient's subjective history provides crucial insights into the nature of their illness. In this case, a 68-year-old Hispanic male presents with a three-day history of sore throat, neck pain, and difficulty swallowing. The absence of systemic symptoms such as fever, chills, cough, nasal congestion, or shortness of breath suggests a localized infectious process. The patient reports no sick contacts, and recent COVID-19 testing was negative, which is pertinent given the prevalence of viral illnesses. Past medical history, including hypertension, diabetes, hypothyroidism, and hyperlipidemia, is noted but does not directly influence the presentation. Review of systems reveals no other complaints, supporting an isolated oropharyngeal pathology.

Objective Findings

Physical examination confirms an overall well-appearing patient with stable vital signs. Key findings include erythema of the posterior oropharynx without exudate or cobblestoning, which is common in viral pharyngitis. No lymphadenopathy or thyroid enlargement is observed. The ears and nose examination are unremarkable, and lungs are clear, reducing concern for lower respiratory involvement. Cardiovascular assessment shows normal heart sounds without murmurs. Notably, the neck exhibits tenderness but no lymph node enlargement. The absence of signs of airway obstruction or systemic illness suggests a non-bacterial etiology.

Assessment

Based on the subjective and objective data, the primary diagnosis is viral pharyngitis, which is the most frequent cause of sore throat in adults. Differential diagnoses include streptococcal pharyngitis, though less likely given the absence of fever and classic presentation. Allergic rhinitis could mimic some symptoms but is less supported by the clinical findings. Other considerations include infectious mononucleosis, which typically presents with lymphadenopathy and systemic symptoms, and herpetic pharyngitis, which would show vesicular lesions. The negative rapid strep test supports a viral etiology.

Plan

Diagnostics: A rapid antigen detection test (RADT) was performed, returning negative, supporting the viral diagnosis. If symptoms persist beyond 5-7 days or worsen, throat culture or additional testing may be necessary to rule out bacterial infection or other causes.

Treatment: Focused on symptomatic relief and supportive care:

• Encourage increased fluid intake to hydrate mucous membranes.
• Advise rest and avoidance of irritants such as smoking or pollutants.
• Recommend OTC analgesics such as acetaminophen or NSAIDs for throat pain and fever reduction.
• Suggest throat lozenges and saltwater gargles to soothe inflamed tissues.
• Use antihistamines if allergy symptoms are suspected.

Education: Emphasize the viral nature of the illness, importance of hand hygiene, and avoiding close contact to prevent spread. Advise the patient to avoid alcohol and smoking during recovery to reduce mucosal irritation. Highlight warning signs warranting immediate medical attention, such as difficulty breathing, swallowing, or persistent high fever.

Follow-up: Schedule follow-up in 3-4 days if symptoms do not improve or worsen. Advise return to clinic if new symptoms such as difficulty breathing, chest pain, or signs of secondary bacterial infection occur.

References:

• Cash, J., & Glass, C. (2017). Family Practice Guidelines. Springer.
• Stead, W. (2019). Symptomatic Treatment of Acute Pharyngitis in Adults. In L. Kunnis (Ed.). UpToDate.
• Stevens, D. L., et al. (2012). Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Clinical Infectious Diseases, 55(10), e86-e102.
• Williams, C. P. (2019). Infectious Diseases of the Throat. Journal of the Royal Society of Medicine, 112(7), 262-266.
• McIsaac, W. J., et al. (2014). Diagnostic accuracy of rapid antigen detection tests for streptococcal pharyngitis. Cochrane Database.
• Shulman, S. T., et al. (2012). Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis. Pediatrics, 130(3), e925-e929.
• Rosenfeld, R. M., et al. (2015). Clinical practice guideline: The diagnosis and management of sinusitis. Otolaryngology–Head and Neck Surgery, 152(2_suppl), S1–S39.
• Cohen, J. (2016). Antibiotic stewardship and the management of sore throat. Journal of Antimicrobial Chemotherapy, 71(5), 1224–1231.
• Bachowski, M., et al. (2018). Differentiating viral and bacterial throat infections: Overview and current perspectives. Infectious Disease Clinics of North America, 32(1), 69–87.
• Shapiro, D. M., et al. (2013). Augmenting the clinical diagnosis of streptococcal pharyngitis with laboratory testing. Journal of General Internal Medicine, 28(1), 71–78.