case study

Week 5 Soap Note

Submit a correctly formatted SOAP note on the identified patient type in a Word document. If the identified patient type was not seen during your clinical, please contact your professor for a patient profile.

Patient type: Adult Psychiatric – A 30-year-old African American male presented to the clinic with his female partner with complaints and symptoms of major depression.

Please add citations to every idea in the assessment, planning, Education, follow-up, and diagnosis areas. Every idea must be cited and referenced in 7th APA format.

It requires a primary Diagnosis and 3 different diagnoses, all with ICD-10 codes.

·
Please use evidence-based references, guidelines used in the management of major depression.

Sample required Soap Note:

SOAP Note Week Four

Student Name

Name of Institution

Course Name:

Professor’s Name followed by credentials

October 1, 2020

SOAP Note Week Two

ID: M M, DOB 1/1/2000, age 20, Hispanic male presents to the clinic unaccompanied and appears to be a reliable historian.

Subjective:

CC: “Cough, runny nose, and sore throat for 7 days”

HPI:

28 year old Hispanic male presents to the clinic unaccompanied, complaining of non-productive cough, runny nose and sore throat x 7 days (1/7/2020). Currently, he reports his symptoms are controlled with Dayquil and Nyquil. He reports his cough as mild, worsened when lying flat. Reports intermittent chills with highest temp at home was 99 degrees. Patient is here to see if he needs antibiotics. He rates his pain in his throat as 4/10, described as “aching, swallowing makes it worse”, relieved by Dayquil/nyquil but returns when that wears off after an hour. Denies headache, denies being around any other sick contacts and denies recent travel.

Past Medical History:

·
Medical problem list

Asthma until high school,

Chickenpox at age 2

Sinus infections-chronic, GERD

·
Surgical:

Tonsillectomy (1998),

Wisdom Teeth Removal (2005)

Allergies:

No known drug allergies.

Food allergies:Strawberries (rash),

Denies seasonal allergies

Medications:

1. Dayquil 15ml 3-4 times daily

2. Nyquil 15ml HS

3. No prescription medications, denies NSAID use or Tylenol

Vaccinations:

Received all childhood vaccines

Last flu shot given Oct 2019.

Social History:

Chemical history:

Denies tobacco/e-cigarette use.

Occasional beer once every 2-3 months. Last drink 2 months ago

Engaged, works in IT, Hobbies include archery.

Family History:

Mother age 60-Diabetes II (deceased)

Father age 61, HTN, DM
Sister 42yo HTN
Maternal Grandma Dementia Deceased age 67

ROS:

General: Denies weight change, weakness, fatigue,
(+)fevers..

Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred vision, or blindness.
EarsNose/Throat/mouth: no hearing changes, tinnitus, earaches, infection, discharge.

(+) FOR RHINORRHEA. No sinus pain or epistaxis.
(+) SORE THROAT,

(+) HOARSE VOICE. No bleeding gums, dentures, sore tongue, dry mouth.

Last dental exam was 4 months ago.

C/V: Denies chest pain, palpitations.
Pulmonary:
(+)NON-PRODUCTIVE COUGH, denies hemoptysis, dyspnea, wheezing, pleuritic pain
Neuro: Denies headache, dizziness, focal numbness/weakness, nausea, vomiting.

Lymph: Denies swollen lymph nodes in neck.

Allergy/immunology: Denies seasonal or environmental allergies
(+) chronic sinus

infections

Objective

VS: T – 98 P – 80 R – 16 BP – 128/72 O2 sat – 99% – 4/10 pain in throat. Wt: 205 Ht: 72 in BMI: 27.8

Labs, radiology or other pertinent studies: Rapid strep negative this visit

Skin: Natural in color, warm, smooth and dry. Good skin turgor, no lesions, rashes, ecchymosis or moles. Nails without clubbing or cyanosis.

HEENT:
Ears: pinna clean, no exudate noted. TM intact and pearly gray with cone of light bilat.
Nose: nasal mucosa
reddened.
Inferior turbinates with bilateral erythema with

clear exudate. Nares patent bilat. No sinus pain upon palpation. Septum midline.
Throat: oral mucosa with
erythema, tongue mobile without lesions, tonsils absent.
Neck: non-tender cervical area, no lymph nodes palpable. Non-enlarged thyroid

palpated. Trachea midline.
Neuro: Alert and oriented x 4. Appropriate, answers all questions.
Cardio: RRR. Crisp S1 S2 without clicks or murmurs.

Thorax and lungs: Thorax is symmetric with good expansion. Respirations are even and unlabored. No use of accessory muscles, stridor, grunting, or nasal flaring. Lungs CTA Bilaterally.

(***notice not all systems are in the PE when doing a focused exam on a problem)

A:

Differential DDX: INCLUDE AT LEAST 3 DIFFERENTIALS

1. Viral pharyngitis – most likely as evidenced by clear exudate in nares, sore throat, cough, low grade fever (Stead, 2019). (←←←←←that is a practice treatment guideline)

2. Strep Throat – not as likely; low grade fever could be higher but Nyquil/Dayquil contains Tylenol but appearance and 7 days duration, lack of sick contacts and negative rapid strep test performed here in office this visit (Stead, 2019).

3. Allergic rhinitis – no report of sx increasing with outdoor activity or exposure to allergens, sx with sore throat are less likely for allergies.

4. Sinusitis- he has chronic infections with current erythema in turbinates, however he has no pain on palpation of sinus cavities, exudate is clear, his nares are patent, and he reports no pressure.

DX: Viral pharyngitis

Plan:

· Diagnostics

In house throat swab for rapid strep – negative.

Chest Xray, CBC, BMP (Stead, 2019).