Focused Soap Note with Rational Case Study

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SUBJECTIVE	Rationale for why the included information is pertinent
ID: JA
CC: The patient notes the following complaints: discomfort and pain when swallowing, especially in the morning, dryness, sore throat, the sensation of a foreign body in the throat, and sub-febrile temperature.
HPI Demographics: Name: JA Age: 30 Race: American Gender: Male DOB: XX/XX/1993 Occupation: Chief Accountant Residence: San Francisco Mother is alive having chronic tonsillitis, no information about other health issues Father is alive and experiencing hypertension, there is information about stroke, but other information is absent. JA has no children or siblings, so no information about their health issues could be found.	The general data about the patient provides the opportunity to estimate the known age-group risks.
PMH Baseline statement of health: previously felt healthy, the problems occurred recently, and there is no significant PMH to mention. Childhood Illnesses: The only things worth noting are recurring sore throats in childhood and regular throat problems. Acute tonsillitis was diagnosed twice over six years ago, but now the patient has no such symptoms. Surgeries/Trauma/Transfusions: The patient has not experienced any surgeries, trauma, or transfusions. Adult Medical Illnesses/Diagnoses: The patient cannot recall any significant adult illnesses beside the chronic tonsillitis. The patient has yet to receive any diagnoses within the past year. The patients surgical and psychiatric surgery is absent.	PMH allows the clinician to understand the background of the illness’s development. It also enables an understanding of which potential diseases can occur further (Obtaining a patient history, n.d.).
Health Maintenance There are no effective health maintenance procedures that the patient follows. JA does not follow a healthy diet. JA has been smoking for over five years now. FM Grandparents: Maternal Grandparents are alive, reporting no significant health issues. Grandfather is 70, and grandmother is 65. Paternal Grandparents: The grandmother is deceased. The cause of death is lung cancer. Grandfather is alive having diabetes type II. Both grandparents are 70. Parents: Mother is alive having chronic tonsillitis, she is 50. Father is alive and experiencing hypertension, he is 51. JA has no children or siblings. SH JA lives alone and reports not being sexually active. The patient has a Bachelor’s degree in accounting and is currently a Chief accountant. The patient is mostly busy with work and spends time with friends on weekends. Currently, he lives alone, spending his free time playing computer games. His hobby is streaming walkthrough games. Accordingly, the lifestyle is entirely sedentary, with almost no physical activity. The main stressors come from work, and the patient finds support in friends with whom he communicates through online games and meets on weekends. The patient notes that he is skeptical about religion. The patent reports drinking wine only and smoking constantly. The patient has no allergies. There is no information about medical interventions and psychiatric history. The patients parents had stroke, so the patient is likely to this disease.	The health maintenance information is vital to understand the patient’s relation to health and possible consequences. The information about the family members is essential to establish the possible illness-related genetic correlations (How to take medical history of a patient, 2023). SH provides information about the additional risks to the patient’s health (What is history taking in optometry, n.d.).
ROS General: Constitutional: swollen lymph nodes Lympth: swelling of the nasopharynx purulent discharge from the tonsils Mouth/throat: redness of the throat and tonsils Body: temperature increase, dyspnea, arrhythmia CV: denies chest pain Resp: has cough GI: denies heartburn orindigestion Newro: denies stroke Psych: denies anxiety
OBJECTIVE: The main goal is to offer recommendations for the treatment of this disease, taking into account the medical history of the patient.
ASSESSMENT: As a result of the assessment, itcan be concluded that the patient suffers from chronic tonsillitis, which results in follicular tonsillitis at this moment. This is an acute infectious disease, usually of a bacterial nature, manifested by damage to the follicular apparatus of the tonsils (usually palatine), an increase in regional lymph nodes, and symptoms of general intoxication.
Differential Diagnosis: Catarrhal tonsillitis is excluded since there is infiltration and swelling of the palatine tonsils and the presence of yellowish-white purulent points on the surface of the tonsils, which are symptoms of follicular tonsillitis (Chan, et al., 2019).
PLAN: The main goals of treating follicular angina are the elimination of the inflammatory process in the tonsils and surrounding tissues. With the bacterial (mainly streptococcal) nature of angina, antibacterial therapy is used with antibiotics of the penicillin series (Chan, et al., 2019). To eliminate the infectious-allergic process, which often accompanies local and systemic manifestations of follicular tonsillitis, antihistamines, and non-steroidal anti-inflammatory drugs are prescribed according to indications (Houborg & Klug, 2022). It is recommended to rinse the pharynx with antiseptic agents (solutions of uracil and hydrogen peroxide, decoctions of medicinal herbs) and use physiotherapeutic procedures during convalescence. In addition, detailed illustrations and photographs help understand and identify different medical conditions and abnormalities (Bickley et al., 2021).
Billing CPT code:

References

Bickley, L.S., Szilagyi, R.G., Hoffman, R.M., & Soriano, R.P. (2021) Bates’ guide to physical examination and history taking. (13th ed.). Wolters Kluwer. ISBN 978-1-496-39817-8

Chan, M., Chen, Z., Chan, P., Hui, M., Lam, E., Ngai, C., Wong, P., & Yeoh, Y. (2019). The human oral cavity microbiota composition during acute tonsillitis: A cross-sectional survey. BMC Oral Health, 19, 275–279. Web.

Houborg, H., & Klug, T. (2022). Quality of life after tonsillectomy in adult patients with recurrent acute tonsillitis: a systematic review. European Archives of Oto-Rhino-Laryngology, 279, 2753–2764. Web.

How to take medical history of a patient. (2023). Medical Study Zone. Web.

Obtaining a patient history. (n.d.). Basicmedical Key. Web.

What is history taking in optometry? (n.d.). Library Answer. Web.

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