Sore Throat SOAP Note Medical Transcription Sample Report
CHIEF COMPLAINT: Sore throat.
SUBJECTIVE: The patient is complaining of sore throat for a few days. She has a bad cough and stuffy nose. No fever. Her sister was just diagnosed with strep and dispensed a course of amoxicillin. She has had an ear infection in the past.
OBJECTIVE: The patient is ambulatory. She appears well. She is not in any distress. Her temperature is 98. HEENT: Both tympanic membranes are clear. Both conjunctivae are clear. Nose is clear. Mouth is clear. There is no tonsillopharyngeal redness. There is no neck gland enlargement. Chest and lungs are clear. Heart: Normal. Abdomen: Benign. Skin: No rash.
ASSESSMENT: Upper respiratory infection and pharyngitis, most likely viral.
PLAN: Rapid strep test will be done and a throat culture will be sent to rule out the possibility of strep. Meanwhile, management is supportive and symptomatic.
Sample #2
CHIEF COMPLAINT: Sore throat.
SUBJECTIVE: The patient has a cough and a cold for about 1-1/2 weeks now that is clearing up, but yesterday and today, his nose was very runny. His neck glands are enlarged. Mom looked into his throat, his throat was red, and there were some white fine spots. He was exposed to a friend who had strep on Saturday. He had pneumonia last year. He does not have asthma.
OBJECTIVE: The patient is awake, alert, not in distress. Temperature is 100. HEENT: Both tympanic membranes are kind of reddish. He is nasally congested. Mouth is clear. There is moderate redness of the tonsillopharyngeal area, and there are some fine spotty exudates on the tonsils. Neck glands, anterior cervical glands are enlarged. Neck is supple. Chest and Lungs: Clear. Heart: Normal. Skin: No rash.
LABORATORY DATA: Rapid strep test was done and that is positive.
ASSESSMENT: Acute strep pharyngitis, upper respiratory infection.
PLAN: The patient will be treated with amoxicillin 250 mg/5 mL. He will take 2 teaspoons 3 times daily for 10 days.
Sample #3
CHIEF COMPLAINT: Sore throat.
SUBJECTIVE: The patient is a (XX)-year-old female with past medical history significant for asthma, coming for a brief office visit today. According to the patient, she is having sore throat for the last 2 to 3 days. It hurts to swallow. She does not give any history of fever. Now, she has trouble breathing. She has occasional cough. She has been wheezing. The cough is mostly dry in nature. She has been using the inhaler. So far, she has been taking some Motrin over-the-counter.
OBJECTIVE: On examination today, she is afebrile. Her blood pressure is 136/84, heart rate is 90, weighs 243 pounds, current temperature 98.2. Pain is 4/10 in intensity. HEENT: Bilateral eardrum partially visualized because of the wax, appeared normal. Oral mucosa moist. Minimal erythema to posterior pharynx. No exudate seen. Nasal mucosa: Moist. No congestion. No sinus tenderness. No lymphadenopathy. Lungs: She has diffuse scattered wheezing. Heart: S1, S2 normal. Regular rate and rhythm. The patient’s O2 saturation is 97% on room air.
ASSESSMENT AND PLAN: This is a (XX)-year-old female with a sore throat, asthma exacerbation. We will start with a rapid strep. The patient received albuterol nebulizer during the office visit. The wheezing did improve. Given the excellent saturation, we will hold off on the x-ray for now. We will treat with amoxicillin and a prednisone taper. The patient recently was treated with a Z-Pak. Anytime there is worsening or shortness of breath/wheezing, she is to contact the office.
