Regional History and Examination (SOAP) Note

Subjective 

History of the Presenting Illness 

H.K., a healthy looking 28-year old African American presence at the clinic complaining of a bothersome white bump at the back of her throat that is making it hard for her to swallow. The client noticed that there was something wrong with her throat three days ago after she started feeling pain when swallowing saliva and asked his wife to check his throat, and she reportedly identified a white bump. The patient notes that she only feels pain when swallowing and her symptoms have not worsened nor improved since she identified the illness. However, the patient does not remember eating any food that could have caused throat irritation. The patient also denies experiencing chills, fever, pain, nasal congestion, scratchy or a sore throat, earache, or post-nasal drip. Moreover, the patient denies having a history of streptococcal infections or using OTC medication. For the first time, she gargled with warm salt water last night. 

Medications : Nexplanon inserted on her right arm in 2017 

Allergies : Denies environmental, food, and medications allergies 

Previous Medical History : Denies previous medical history 

Previous Surgical History : Denies 

Gynecologic History : 

Menses: 

Menarche: 14-years-old 

LMP: light bleeding 

GYN: Pap Negative 

Menses: Irregular with Nexplanon 

Sexual History: 

Sexually active with 2-lifetime sexual partners 

Uses condoms 

Contraceptive History: 

Nexplanon 

STIs: Denies history of STIs 

Psychosocial History : 

Employed as a sales associate at ABC logistics company 

Denies the use of illicit drugs or tobacco 

Lives with her husband and two children 

Denies history of a violent intimate partner 

Consumes alcohol socially, approximately 2 to 3drinks a week 

Denies a history of psychiatric disorders or current feelings of depression or anxiety 

Health Maintenance : 

Denies a series of HPV vaccines 

Up-to-date, according to the patient 

Denies having received the seasonal influenza vaccine 

Family History : 

There is no history of cancer in the family 

Mother: diabetes type 2 

Father: Hypertension 

Review of Systems : 

General: 

The patient is sleeping well 

No fever, headache, nausea or vomiting, fatigue, and chills 

No rapid weight gain or loss 

HEENT: 

No eye discharge or changes in vision 

Denies changes in hearing or an earache 

No sinus congestion, rhinorrhea, or nasal congestion 

Experiencing intermittent throat irritation when swallowing for three days but the irritation does not radiate 

No history of streptococcal bacterial infection 

Patient denies scratchy, sore, or dry throat as well as postnasal drip 

Musculoskeletal: 

The patient does not experience weakness, pain, or body aches 

Respiratory: 

The patient denies experiencing nasal congestion, cough, and shortness of breath 

Gastrointestinal: 

Patient has regular bowel movements 

Does not experience abdominal pain, constipation, or diarrhea 

Objective 

Vital Signs 

Height 5’2” 

Weight 136 lb. 

BMI 24.9 kg/m2 

RR 16 

BP 108/72 mm Hg 

HR 76 beats/min 

Temperature 98.8  F (oral) 

Labs: Rapid Strep Screen, Negative 

General : Healthy-looking woman, sits comfortably and calmly on the examination table. She is neatly dressed and clean and speaks in full sentences. 

HEENT: 

Head: No edema, maxilla or frontal sinus tenderness, and normocephalic 

Eyes: Pupils are round, reactive to light, and equal, and no discharge 

Ears: Tympanic membranes are intact, and there are no fluids in canals 

Nose: No nasal discharge, the nasal mucosa is intact and pink 

Throat: Thyroid gland does not have palpable nodules, and it is not enlarged, tonsils are not enlarged bilaterally, the white lesion is 1mm round, and the right tonsil is surrounded by approximately 2mm or erythema. There is no odor or discharge. 

Lymph Nodes: The lymph nodes are neither tender nor enlarged 

Cardiovascular: The sinus rhythm and rate is normal, and the capillary refill is below 3 seconds 

Respiratory: Breath sounds are cleat with no adventitious sounds 

Integumentary: The patient’s skin is dry and warm with no signs of varicose veins and edema 

Gastrointestinal: The abdomen is non-tender and soft, and the four quadrants demonstrate normoactive bowel sounds 

Assessment 

Assessment: Pharyngitis that is secondary to irritation by a foreign body 

Differential Diagnoses: 

Streptococcus pharyngitis 

Viral pharyngitis 

Tonsillolith 

Rationale: 

The rapid strep screen that was conducted turned out negative for Streptococcus group A. The physical exam is normal apart from the inflamed white lesion on the right tonsilar area. The examination demonstrates that the patient is suffering from pharyngitis caused by such secondary bodies as food with differential diagnosis of tonsillolith, viral pharyngitis, and streptococcus pharyngitis. Pharyngitis is commonly a viral infection and often accompanied by such symptoms as a headache, cough, mild fever, and hoarseness (Weiss, 2017; Ruppert & Fay, 2015). However, the patient indicates that she is not experiencing other symptoms apart from the lesion that disturbs her when she swallows. Bacterial pharyngitis commonly emanates from group A streptococcus, and it is only responsible for 5 to 15% of infections in adults (Ruppert & Fray, 2015). 

The second differential diagnosis, tonsillolith, refers to a solid mass that is located n the tonsilar crypt with live biofilm and often varies in size (Yellamma-Bai & Vinod-Kumar, 2015). The significant symptoms of tonsillolith include feeling a foreign body in the throat during swallowing, halitosis, pharyngitis, and dysphagia (Takahashi et al., 2017). After examining the differential diagnosis, pharyngitis that is secondary to irritation from a foreign body is the ideal diagnosis. This is attributed to the fact that the patient does not demonstrate other symptoms, particularly relating to bacterial or viral pharyngitis. Further, given that tonsillolith is rare in adults, the most appropriate explanation for the patient’s problem is that the client’s throat got irritated by something that she ingested, leading to the inflammation of the tonsilar area. 

Plan 

The throat culture is sent to the lab 

Patient advised gargling with warm salt water for a week, two times daily 

The patient is educated on how to avoid hard foods and advised to consume soft diets until she recovers 

The patient is sent to an ENT specialist if there is no change in two weeks. 

Rationale: 

Although the rapid strep throat culture turned negative for group A streptococcus, further tests are essential in case there is no change within the specified period to test the group G and C streptococcus species (Pelucchi et al., 2012). The tests would help in administering the appropriate medications to the patient if the symptoms worsen or indicate infectious pharyngitis. Presently, antibiotic therapy is not recommended since the test for group A streptococcus turned negative and the treatment is not ideal for low-risk patients (Pelucchi et al., 2012). Moreover, the lesion is not infected, indicating that antibiotics are not necessary. The patient is advised to avoid hard foods, which can further scratch and irritate the throat. In case the warm salt water intervention does not eradicate the symptoms, the patient is recommended to an ENT specialist for further evaluation. 

References 

Pelucchi, C., Galeone, C., Grigoryan, L., Verheij, T., Esposito, S., Huovinen, P., & Little, P. (2012). Guideline for the management of an acute sore throat: ESCMID sore throat guideline group C. Clinical Microbiology and Infection, 18 (1), 1-28. doi:10.1111/j.1469-0691.2012.03766.x 

Ruppert, S. D., & Fay, V. P. (2015). Pharyngitis: soothing the sore throat. Nurse Practitioner, 40(7), 18-26. doi:10.1097/01.NPR.0000466498.57296.60 

Takahashi, A., Kudoh, T., Ohe, G., Takamaru, N., Tamatani, T., Nagai, H., & ... Sugawara, C. (2017). Prevalence and imaging characteristics of palatine tonsilloliths evaluated on 2244 pairs of panoramic radiographs and CT images.  Clinical Oral Investigations, 21 (1), 85-91. doi:10.1007/s00784-016-1752-0 

Weiss, M. (2017). Pharyngitis.  Magill’s Medical Guide [Online]. Retrieved from Research Starters, EBSCOhost. 

Yellamma-Bai, K., & Vinod-Kumar, B. (2015). Tonsillolith: A polymicrobial biofilm. Medical Journal Armed Forces India, 71S95-S98. doi:10.1016/j.mjafi.2011.12.009