HEENT SOAP Note

Week 5- Discussion
CASE STUDY 2: Focused Throat Exam

***NOT AN AMA paper- please use the attached SOAP note*

Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus during the past 2 weeks, Lily figured she shouldn\’t take her 3-day sore throat lightly. Your clinic has treated a few cases similar to Lily\’s. All the patients reported decreased appetite, headaches, and pain with swallowing. As Lily recounts these symptoms to you, you notice that she has a runny nose and a slight hoarseness in her voice but doesn\’t sound congested.

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In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.
Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.
Using the Episodic/Focused SOAP Template:
· Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned.

· Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.
· List five different possible conditions for the patient\’s differential diagnosis, and justify why you selected each

SAMPLE SOLUTION

Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
L.K, 20 years, Female, African American
SS.
Patient reported having a sore throat
HPI:
Location: head
Onset: 3 days ago
Character: flu-like symptoms, running nose and slight hoarseness in the voice although the chest doesn’t look too much congested
Associated signs and symptoms: reduced appetite, headaches, pain during swallowing,…