develop a focused SOAP note based on evidence-based approaches. 

Patient information: John Doe Name: John Doe, 45 years of age Gender Male Principal complaint: Sore throat & cough

John Doe, a 45 year-old man with a cough and sore throat that began two days prior. No fever, no chills or chest pain are reported by the patient. The patient has used over-the counter cough and throat lozenges that provided some mild relief.

The Vital Signs

• Blood pressure 120/80 mmHg
• Heart rate: 80 Beats/Minute
• Respiratory Rate: 16 breaths/min
• Temperature: 98.6°F

The Physical Examination:

• Head and Neck: no tenderness or swelling is noted
• Ears: clear bilaterally
• Remove the nose bilaterally
• Tonsils and pharynx: mild swelling and redness of the tonsils with exudate from the tonsils. No lesions or ulcers were noted. No lymphadenopathy cervicalis was noted.
• Lungs: clear to bilateral auscultation
• The heart beats at a regular rate with no gallops or murmurs.

A: Based on the patient’s history and physical exam, the most likely diagnosis is acute pharyngitis. The differential diagnosis includes viral upper respiratory infections, tonsillitis, streptococcal pneumonia, and tonsillitis.

P:

1. Treatment for symptomatology:

• Acetaminophen (650mg) every 6 hours, as required for pain and fever
• Use chloraseptic throat spray as required
• Keep using over-the-counter throat and cough lozenges

2. Tests for diagnostic purposes

• Test rapid strep to eliminate streptococcal pneumonia

3. Follow-up and education:

• Encourage the patient to complete the course of anti-biotics after streptococcal infection is confirmed.
• To prevent infection, advise the patient to drink lots of fluids and to practice good hand-hygiene.
• Schedule a follow-up appointment in 48-72 hours to assess the patient’s response to treatment and review results of rapid strep test.

According to evidence-based practices, antibiotics are not prescribed for acute pharyngitis until the rapid strep tests is positive. This helps to reduce the use of antibiotics, decrease antibiotic resistance and minimise adverse effects. In most cases, symptomatic therapy and supportive care is sufficient for acute pharyngitis.