SOAP Note

Subjective:

The patient is a 17-year-old female presenting with complaints of fever, cough, ear pain, and sore throat. She has been experiencing a persistent fever for the past 7 days, accompanied by a severe cough and generalized body pain, including ear discomfort.

Objective:

• Vital signs and physical examination findings are not fully provided, but the patient has been taking Tylenol for symptom management.
• Laboratory results:
  • CBC: Hematocrit 34.7, lymphocytes absolute 0.9
  • CMP: Glucose 127, sodium 135, potassium 3.0, alkaline phosphatase 47
  • CRP: 103
  • Lactic acid: 1.1
• Negative tests for RSV, influenza A and B, COVID, and strep.
• Chest X-ray shows lateral right mid and lower lung consolidation compatible with pneumonia.

Assessment:

The differential diagnosis for this patient can be categorized as follows:

• Single Most Likely Diagnosis
  • Community-Acquired Pneumonia (CAP): Given the patient's symptoms (fever, cough, body pain) and the chest X-ray findings of lung consolidation, CAP is the most likely diagnosis. The elevated CRP and the presence of consolidation on the chest X-ray support this diagnosis.
• Other Likely Diagnoses
  • Mycoplasma pneumoniae infection: This is a common cause of pneumonia in young adults, especially with symptoms like cough and fever. The fact that other common pathogens (influenza, RSV, COVID, strep) have been ruled out makes this more likely.
  • Influenza-like illness due to another viral pathogen: Despite the negative influenza test, other viral pathogens could cause similar symptoms and should be considered, especially given the seasonal context.
• Do Not Miss Diagnoses
  • Severe bacterial pneumonia (e.g., due to Streptococcus pneumoniae): Although the strep test is negative, this could be a false negative, especially if the patient has been taking antibiotics or the test was not sensitive enough. Severe bacterial pneumonia requires prompt antibiotic treatment.
  • Pneumonia due to atypical bacteria (e.g., Legionella, Chlamydophila pneumoniae): These pathogens can cause severe pneumonia and have different treatment requirements than typical bacterial pneumonia.
  • Sepsis: Given the patient's fever, elevated CRP, and low lymphocyte count, sepsis should be considered, especially if there are signs of organ dysfunction (e.g., low potassium, elevated glucose).
• Rare Diagnoses
  • Tuberculosis (TB): Although less likely in an immunocompetent young adult without risk factors, TB can present with similar symptoms and should be considered if the patient has been exposed or has risk factors.
  • Fungal pneumonia: This would be unusual in an otherwise healthy young adult but could be considered if the patient has been exposed to certain environments (e.g., bird droppings) or has a compromised immune system.

Plan:

• Further diagnostic workup may include blood cultures, sputum Gram stain and culture, and possibly serologic tests for atypical pathogens.
• Empiric antibiotic therapy should be started, covering common causes of CAP, including atypical bacteria.
• Supportive care for symptoms, including antipyretics and analgesics.
• Monitoring for signs of sepsis or respiratory failure, which may require ICU admission.