Focused SOAP Assessment: Ear, Nose and Throat
S.
Name: L.K, Age: 20yrs, Sex: Female, Race: American
CC (chief complaint: L. K is a 20-year-old patient presenting to the hospital with complaints of a headache. She reports that “I have been having mild headaches for three days now, but today it has intensified. I have also lost my appetite since yesterday, and as I try to swallow something, it becomes painful.”
HPI: The patient is a 20-year-old American female presenting to the hospital with a headache and dysphagia. On the assessment of the patient the following are noted:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: Photophobia, reduced appetite, and dysphagia.
Timing: After walking for a short distance or when doing any activity that requires bending of the head.
Exacerbating/ relieving factors: Taking a nap and resting for a long period.
Severity: 7/10 pain scale
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Soc Hx: The patient is an athlete, and she does regular exercises. She goes for a morning and evening run every day and spends most of her time with friends apart from the studies. Her diet is mainly made up of greens and fruits. The patient does not drink or smoke. The patient reports that her living environment is made up of smokers and alcohol addicts. Three of her neighbors drink alcohol. Her safety during driving and cycling is well covered as she uses seat belts and helmets as protective measures.
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ROS
GENERAL: The patient is sick looking with some weakness. No weight loss or fever observed.
HEENT: Eyes: Appear red and wet as a result of a headache. There is no discharge from the ears and patient reports a good hearing ability. She has a running nose and slight hoarseness on her voice.
SKIN: No rash or itching.
CARDIOVASCULAR: The heart rate is at 78b/m, and the capillary refill is at 2 seconds. There is no central or peripheral cyanosis. No edema or chest pain observed.
RESPIRATORY: The patient breathes with ease at the rate of 20b/m. Chest expansion and recoil are good. No abnormal breath sounds detected.
GASTROINTESTINAL: There is no complaint of nausea and vomiting. She complains of decreased appetite, and she experiences pain when swallowing food or water. The consistency and pattern of the stool are normal.
GENITOURINARY: No complaints of anuria, dysuria, polyuria or hematuria. The last menstrual period was on February, 5th, 2017.
NEUROLOGICAL: Orientation to time, place and person is present. The patient has a headache that has lasted for three days. There is no, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: The patient reports weakness on the muscles especially after doing strenuous activity. No joint pain or stiffness observed.
HEMATOLOGIC: No anemia, bleeding or bruising observed.
LYMPHATICS: The lymph nodes on the cheek are slightly enlarged. There is no history of splenectomy.
PSYCHIATRIC: The patient has no history depression or anxiety.
ENDOCRINOLOGIC: Patient reports sweating at night. No polyuria or polydipsia.
ALLERGIES: Patient is allergic to eggs.
O.
Physical exam:
Vital signs: Temperature is 36.7 degrees, pulse 78b/m, respiration 20b/m and blood pressure 126/84mmhg.
HEENT: Eyes: Appear red and wet as a result of the headache. There is no discharge from the ears and patient reports a good hearing ability. She has a running nose and slight hoarseness on her voice.
Chest: The chest is normal, no scars observed. Expansion and recoil are good. On auscultation, the heart sounds are well heard with no murmurs.
Abdomen: It is symmetrical without distention, and the bowel sounds are normal. On palpation, the liver and the spleen are normal in size.
Limbs: Capillary refill is at 2 seconds. No cyanosis observed. Femoral, popliteal, brachial and radial pulses are present. Patient reports some weakness of muscles after walking for long.
Diagnostic results: Laboratory diagnosis of the patient will involve culture and sensitivity tests to determine the exact cause of the disease (Richter et al., 2016). A nasal swab is used to test for flu while a throat swab is used to test for pharyngitis.
A.
Differential Diagnoses
Flu: It is a viral infection that affects the respiratory system. The common manifestation of the condition is a headache, fatigue and muscle weakness. The condition also manifests with GIT symptoms like nausea, dysphagia, decreased appetite and diarrhea in children (Benjamin and Bahr, 2016). The patient manifests with a sore throat, dysphagia, running nose and headache giving flu the primary diagnosis.
Cold: It is a viral condition that affects the upper respiratory tract. Colds manifest with running nose, sore throat, headache, and cough. According to Mossad (2015), the condition also manifests with mild fatigue, low-grade fever, and congestion. It is likely to be a diagnosis for the patient, but laboratory tests will determine the actual cause. I selected the differential diagnosis because it commonly manifests with the symptoms observed in the patient.
Pharyngitis: It is a sore throat caused by inflammation of the pharynx. According to Gore (2013), the condition manifests primarily with pain that worsens with swallowing, hoarseness of the voice, headache and muscle aches. The patient manifests with the symptoms suggesting a possible diagnosis of Acute Pharyngitis. A swab taken from the throat and tested in the lab will detect the presence of the causal agent.
References
Benjamin, S. M., & Bahr, K. O. (2016). Barriers associated with seasonal influenza vaccination among college students. Influenza research and treatment, 2016.
Gore, J. M. (2013). Acute pharyngitis. Journal of the American Academy of Physician Assistants, 26(2), 57-58.
Mossad, S. B. (2015). Upper respiratory tract infections. Clevel and Clinic. Department of Infectious Disease.
Richter, J., Panayiotou, C., Tryfonos, C., Koptides, D., Koliou, M., Kalogirou, N. … & Christodoulou, C. (2016). Aetiology of acute respiratory tract infections in hospitalised children in Cyprus. PloS one, 11(1), e0147041.
