Episodic-Focused SOAP Note Template-Painful Swallowing and Sore Throat 13-Year-Old Male Patient Information: Name: Jason Age: 13 years

Episodic-Focused SOAP Note Template-Painful Swallowing and Sore Throat 13-Year-Old Male

Patient Information:

Name: Jason

Age: 13 years

Gender: Male

S.

CC “Painful swallowing and sore throat.”

HPI: Jason is a 13-year-old male who presents with complaints of painful swallowing and a sore throat. According to the patient, the symptoms started yesterday and have persisted. They were initially described as a “really bad sore throat.” Jason describes the pain as a sore throat aggravated by swallowing. Associated signs and symptoms include general body weakness, fever, and painful swallowing. The symptoms are especially worse during nighttime. There are no specific exacerbating factors. However, his mother administered over-the-counter Children’s Motrin, which helped to reduce his fever but did not alleviate the sore throat. The patient did not quantify the severity of the pain.

Current Medications: Children’s Motrin (OTC): Dosage: Follows the recommended pediatric dosage. Frequency: As needed. Length of Time Used: Started recently. Reason for Use: To alleviate fever symptoms

Allergies: No known medication, food, environmental allergies, or adverse reactions were reported.

PMHx: There is no history of chronic illnesses, surgeries, or admissions. The patient is currently receiving all age-appropriate immunizations, including the last tetanus vaccination received two years ago.

Soc Hx: The patient is currently a student and has no occupation outside their studies. He enjoys playing soccer and participating in a local child club. There is no history of alcohol or tobacco abuse. The patient lives with their mother and younger sibling. They have a supportive and stable family environment. The patient resides in a suburban area with their family. They have a safe and comfortable living environment with access to necessary amenities.

Fam Hx: His parents are alive and healthy, without any reported chronic illnesses. He has one younger sibling who is in good health and has no known chronic illnesses. His grandparents are all alive and in good health.

ROS:

GENERAL: The patient denies fever, weight loss, fatigue, or chills.

HEAD: No reported headaches, head trauma, or dizziness.

EENT (Eyes, Ears, Nose, Throat):

Eyes: No visual loss, blurred vision, or double vision.

Ears: No hearing loss or ear pain.

Nose: No sneezing, congestion, or runny nose.

Throat: Reports sore throat and painful swallowing.

SKIN: No rash or itching reported.

CARDIOVASCULAR: Denies edema, palpitations, or chest pain.

RESPIRATORY: Denies cough or dyspnea.

GASTROINTESTINAL: No reported nausea, abdominal pain, diarrhea, or vomiting.

GENITOURINARY: Denies dysuria, hematuria, increased frequency or urgency

NEUROLOGICAL: No reported headaches, syncope, or dizziness

MUSCULOSKELETAL: Denies muscle or joint pain, joint stiffness, or back pain.

HEMATOLOGIC: No reported easy bruising, or bleeding

LYMPHATICS: No reported lymphadenopathy

PSYCHIATRIC: No anxiety or depression was mentioned.

ENDOCRINOLOGIC: No reported cold or heat intolerance, sweating, polydipsia, or polyuria.

ALLERGIES: Denies hives, asthma, or allergic rhinitis.

O.

Physical exam:

General: The patient appears to be a 13-year-old male in no acute distress. He is alert, cooperative, and appropriately oriented to person, place, and time. There are no visible signs of discomfort or abnormal behavior.

Head: Normocephalic and atraumatic. No palpable tenderness or deformities were noted.

Eyes: Pupils are equal, round, and reactive to light. Conjunctiva is clear. No scleral icterus or discharge was observed. Extraocular movements are intact. No ptosis or nystagmus was noted.

Ears: Bilateral external ears are symmetrical without swelling or discharge. Tympanic membranes are pearly grey and intact bilaterally. No tenderness or erythema was observed.

Note: No external deformities or tenderness. Nasal passages are patent. No discharge or polyps were noted.

Throat and Oropharynx: Tonsils are enlarged (2+) and erythematous. Tonsil stones are present on the right side. White patches are visible on the tongue. No uvular deviation or exudate was observed. No cervical lymphadenopathy is appreciated.

Neck: Supple. No palpable lymphadenopathy. No thyromegaly or thyroid nodules were detected. No jugular vein distention was observed.

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