Patient Soap Note
Prepared by: [Your Name]
I. Subjective (S)
A. Chief Complaint
The patient reports experiencing a sore throat for the past 3 days, accompanied by mild fever and difficulty swallowing.
B. History of Present Illness
The patient describes the sore throat as constant, with a sharp pain that worsens when swallowing. They also report feeling fatigued and having a low-grade fever of around 100°F. No cough or runny nose was noted. Denies recent contact with sick individuals.
C. Past Medical History
No significant past medical history. The patient is generally healthy with no chronic conditions.
D. Medications
The patient is not taking any regular medications.
E. Allergies
No known drug allergies.
II. Objective (O)
A. Vital Sign
Vital Sign | Value |
|---|---|
Temperature | 100°F |
Blood Pressure | 120/80 mmHg |
Heart Rate | 88 bpm |
Respiratory Rate | 16 breaths/min |
Oxygen Saturation | 98% |
B. Physical Examination
Examination Area | Findings |
|---|---|
General | Alert, well-nourished, and in mild distress due to throat pain. |
Head and Neck | Erythema and mild swelling of the tonsils. No visible exudates. |
Throat | Tender to palpation, no lymphadenopathy. |
Cardiovascular | Normal S1, S2, no murmurs. |
Respiratory | Clear to auscultation bilaterally, no wheezing or crackles. |
C. Laboratory Results
Rapid strep test negative. No other lab work was performed.
III. Assessment (A)
Likely viral pharyngitis, given the absence of significant fever, rash, or pus on the tonsils. The negative rapid strep test supports this diagnosis.
Differential diagnosis includes bacterial pharyngitis, but this is less likely based on the clinical presentation and rapid strep result.
IV. Plan (P):
Plan (P) | Details |
|---|---|
Medications | Recommend symptomatic treatment with acetaminophen for pain and fever. |
Instructions | Advise warm saline gargles and increased fluid intake. |
Follow-Up | Instruct the patient to follow up if symptoms worsen or persist beyond 7 days, or if new symptoms such as rash or difficulty breathing develop. |
Prevention | Emphasize good hand hygiene to reduce the risk of spreading the infection. |
Templates
Note
Templates
