Soap Note #1 Strep Pharyngitis
CHIEF COMPLAINT:
 Sore throat
 Fever
HISTORY OF PRESENT ILLNESS (HPI):
A 19-year old male presents w/a 3day history of sore throat, red and swollen tonsils with
white patches. Pt c/o painful swallowing with associated fever. He states it becomes
worse at night and while drinking or eating. He reports pain 7/10 and no other home
treatment other than Motrin. He is otherwise healthy and is a freshman in college.
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Use mnemonic “OLD CARTS” to clarify the attributes of each system:
O = Gradual started about 3 days ago
L = Throat
D = 3 days and continuous
C = Red and swollen tonsils, white patches and painful swallowing
A = Motrin makes it better, drinking liquids and eating makes it
worse
 R = Fever
 T = Worse at night and continuous throughout the day
 S = 7/10
Home Treatment: Motrin
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PAST MEDICAL HISTORY:
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Childhood Illnesses: Strep throat, ear infection
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Past Medical History: None
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Surgical History:
 Tympanostomy tube, 2009’
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Hospitalizations/Accidents/Injuries: None
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Transfusions: None
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Reproductive/ Gynecologic History; Sexual History:
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Sexual history:
Number of sexual partners- two
Sexual orientation –female partner
History of sexual transmitted infections- None
Safe sex behaviors- Condoms
History of sexual dysfunction-None
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Psychiatric History:
 None
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Medication History:
 Motrin 600mg every 6 hours as needed
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Allergies:
 Bee stings
 If allergic, what type of reaction do they have- Redness and swelling
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Immunizations/Health Maintenance:
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Heath Maintenance:
Eye exam- 4/2010 Results: 20/40 bilateral
Dental exam-7/2017 Results: Normal
Immunizations up to date
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Travel History: None
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Family History:
Father- 47 years old alive, hx of Diabetes and allergies to PCN
Mother- 40 years old alive, hx of Hyperlipidemia and Gout, NKA
Sister -16 years old alive, hx of Anxiety, NKA
Sister- 10 years old alive, no medical hx and NKA
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Psychosocial History:
 Marital status/relationships- girlfriend
 Employment status- unemployed
 Substance abuse – smokes ½ pack every other day, no treatment
 Diet is normal
 Sleep pattern is normal
 Exercise- 4x a week
REVIEW OF SYSTEMS (ROS) –
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General: (+) fever, (+) decrease appetite, (+) pain (-) chills, (-) malaise, (-)
fatigue, (-) night sweats, (-) weakness, (-) unintentional weight loss
Neurological: (-) Fainting, (-) dizziness, (-) seizures, (-) numbness, (-)
tingling, (-) paresthesias, (-) weakness, (-) speech disorders, (-) tremors, (-)
headaches, (-) imbalance, (-) loss of balance or coordination, (-) mood or
temperament changes, (-) memory changes, (-) LOC.
Head: (-) Lumps, (-) asymmetry, (-) trauma, (-) syncope, (-) headache, (-)
dizziness.
Eyes: (-) Pain, (-) redness, (-) itching, (-) burning, (-) discharge, (-) swelling,
(-) excessive tearing, (-) blurring of vision, (-) diplopia, (-) spots, (-)
photophobia, (-) changes in vision or visual fields, (-) glasses/corrective
lenses/contact lens
Ears: (-) Pain, (-) discharge, (-) infections, (-) tinnitus, (-) changes in hearing,
(-) injury, (-) hearing aid,
Nose/Sinuses: (-) Epistaxis, (-) obstruction, (-) airflow, (-) discharge, (-)
olfactory changes, (-) postnasal drip, (-) sinus pain.
Mouth/Throat: (+) sore throat, (+) difficulty chewing or swallowing, (-)
Bleeding gums, (-) sores in mouth, (-) toothache, (-) changes in taste, (-)
dentures, (-) hoarseness, (-) voice changes.
Neck/Nodes: (+) swollen glands, (-) Pain, (-) stiffness, (-) masses, (-)
swelling, (+) swollen glands.
Breast/Axilla: (-) Lumps, (-) discharge, pain, (-) tenderness, (-) dimpling, (-)
contour changes, (-) nipple changes.
Respiratory: (-) Cough, (-) sputum production, (-) hemoptysis, (-) chest pain,
(-) shortness of breath, (-) wheezing
Cardiovascular: (-) Chest pain or tightness, (-) palpitations, (-) dyspnea, (-)
murmur, (-) edema, (-) paroxysmal nocturnal dyspnea, (-) known heart
murmur, (-) edema, (-) phlebitis, (-) calf pain, (-) intermittent claudication, (-)
varicose veins
Gastrointestinal: (+) dysphagia (-) Anorexia, (-) nausea, (-) vomiting, (-)
indigestion, (-) belching, (-) heartburn, (-) hematemesis, (-) abdominal pain,
(-) food intolerance, (-) diarrhea, (-) constipation, (-) change in bowel habits,
(-) bloody or tarry stools, (-) pain or rectal itching, (-) rectal bleeding.
GU: (Genitourinary): (-) Frequency, (-) urgency, (-) burning, (-) dysuria, (-)
hematuria, (-) nocturia, (-) incontinence, (-) change in color or odor, (-) (-)
dribbling, (-) retention, (-) oliguria. (-) ADL: Urinary pattern
 Male Genital: (-) Weak urine stream, (-) discharge from penis, (-)
lesions, (-) testicular pain or swelling, (-) lumps on testicles
Musculoskeletal: (-) Pains in joints, (-) swelling, (-) heat, (-) redness, (-)
stiffness, (-) muscle weakness, (-) muscle aching or pain, (-) back pain or
injury, (-) limitation in movement or ROM.
Integument: (+) moles, (+) birthmarks, (+) Hygiene patterns, (+) sun
exposure, (+) use of sunscreen (SPF70), (-) Rashes, (-) lesions, (-) itching, (-)
dryness, (-) changes in color or texture, (-) changes in hair distribution or
texture, (-) nail changes.
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Lymphatics: (+) lymph node enlargement or tenderness
Endocrine: (-) Temperature intolerance or sensitivity to heat or cold, (-)
polyuria, (-) polydipsia, (-) glycosuria, (-) weight changes, (-) voice changes,
(-) change in glove or shoe size, (-) fatigue.
Hematopoietic: (-) Bleeding tendencies, (-) bruising
Psychiatric: (-) Suicidal ideation, (-) depression, (-) history of mental illness.
PHYSICAL EXAMINATION
General: Well developed, well nourished. No acute distress
Vital Signs: 111/65, 70, 15, 97.9, Weight 135, BMI 23
HEAD: NCAT
NEURO:
Cranial Nerves
CN I, Olfactory: Tested with common scents – normal
CN II: Visual Acuity: Snellen chart 20/40 OS, 20/40 OD 20/40
OU. Near vision is normal. Color discrimination (Ishihara) is
normal
CN III: Oculomotor Nerve: Instruct the patient to follow the
penlight or ophthalmoscope with their eyes without moving
their head- normal
CN IV: Trochlear Nerve: Instruct the patient to follow the
penlight or ophthalmoscope with their eyes without moving
their head-normal
CN V: Trigeminal Nerve: using a pinprick to test facial
sensation and by brushing a wisp of cotton against the lower
or lateral cornea to evaluate the corneal reflex-normal
CN VI: Abducens: Instruct the patient to follow the penlight
or ophthalmoscope with their eyes without moving their
head-normal
CN VII: Facial: Asymmetry of facial movements is often more
obvious during spontaneous conversation, especially when
the patient smiles or, if obtunded, grimaces at a noxious
stimulus; Hyperacusis, indicating weakness of the stapedius
muscle, may be detected with a vibrating tuning fork held
next to the ear-normal
CN VIII: Vestibulocochlear, acoustic, auditory: Hearing is first
tested in each ear by whispering something while occluding
the opposite ear. Testing for Nystagmus may be rotary,
vertical, or horizontal and may occur spontaneously, with
gaze, or with head motion-normal
CN IX: Glossopharyngeal: Check for gag reflex by asking the
patient to say “ah” or using a tongue blade-normal
CN X: Vagus: Check for gag reflex by asking the patient to
say “ah” or using a tongue blade-normal
CN XI: Spinal Accessory: For the sternocleidomastoid, the
patient is asked to turn the head against resistance supplied
by the examiner’s hand while the examiner palpates the
active muscle (opposite the turned head). For the upper
trapezius, the patient is asked to elevate the shoulders
against resistance supplied by the examiner-normal
CN XII: Hypoglossal: valuated by asking the patient to extend
the tongue and inspecting it for atrophy, fasciculation, and
weakness (deviation is toward the side of a lesion)-normal
Cerebellar:
Romberg is negative
Finger to Nose is normal
Heel-to-shin test is normal
Motor: Strength 5/5 in all extremities Pronator drift is not
appreciated
Sensory: Light touch, deep touch, pinprick: normal
DTR:
List each reflex tested and result
Patellar reflex 2+ bilaterally
Biceps reflex 2+ bilaterally
Eyes: PERRLA, EOMI. Periorbital structures are normal – no
swelling, erythema. Fundoscopic exam reveals healthy
vessels, sharp disc margins. No papilledema. Macula appears
normal
Visual Acuity: OD_ 20/40, OS: 20/40, OU 20/40
EARS: external ears are symmetrical. There is no swelling,
redness or tenderness. Mild cerumen bilateral canal. No
drainage, swelling, debris, fb TM: pearly. Normal light reflex,
No erythema, fluid levels.
Nose: External nose is normal – no swelling, tenderness.
Nares are patient. Nasal mucosa is pink and moist. No
polyps, drainage, swelling
Throat: Good dentition. + White patches. The airway is
patent. The uvula is midline, mild exudate with + erythema.
Tonsils are swollen and red.
Neck: Supple, full painless ROM. Negative meningism,
-nuchal rigidity; Kernigs and Brudzinski signs are negative.
There is no appreciable adenopathy. The thyroid gland is
normal in size and is without nodules. +Swelling and tender
lymph nodes.
Chest: Symmetrical expansion, no crepitus, no tenderness.
Lungs: Clear to auscultation with equal breath sounds
Cardiac: S1, S1 are normal. There is no rub, murmur or
gallop. Normal rate and rhythm
Abdomen: The abdomen is soft, non-tender and nondistended. The liver and spleen are non-tender and of
normal size. There is no hernia.
GU: - S/S
Musc/Skel: Full, painless ROM. No swelling, erythema,
tenderness
Integ: Pink, warm dry. No pallor, jaundice. There are no
rashes or lesion
ASSESSMENT (DIAGNOSIS)
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Assessment =Strep Pharyngitis
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List 2 differential diagnosis
1. Infectious mononucleosis
2. Tonsillitis
PLAN
Strep Pharyngitis
 Reduce symptom severity and duration
 Prevent acute complications such as; otitis media, rheumatic fever, peritonsillar
abscess and prevention of spread to others.
 A physical exam will be done along with a rapid antigen test on your throat, if
negative and still suspects strep a throat culture might be done.
 Treatment includes Penicillin V 500 mg TID for 10days, Ibuprofen and Tylenol to
relieve pain and reduce fever.
 Patient education:
1. Keep your hands clean: cover your mouth when you cough or sneeze and
don’t share personal items
2. Gargling with salt water: ¼ tsp of table salt in 8 ounces of warm water
3. Rest, drink fluids and eat soft foods
 No referrals needed at this time
 If left untreated or does not resolve follow up with PMD in 7 days. If recurrent
infections occur an extended or different antibiotic may be prescribed.
Infectious Mononucleosis
 Physical exam of throat and lymph nodes
 Check labs (chemistry, monospot and heterophile antibody)
 Treatment is based on clinical s/s, comfort measures such rest, OTC Tylenol or
Motrin for body aches, fever or headaches.
 Patient Education:
1. Avoid participation in any contact sports for 3-4wks after onset of
s/s to prevent trauma
2. Avoid close to close contact with infected individuals
3. Practice excellent hygienic practices
4. Avoids sharing utensils, toothbrushes and drinking glasses
5. S/S usually improve within one to two weeks
 Referrals depends on if there are any complications such as rupture of spleen,
pericarditis, myocarditis, encephalitis. In that case; hematologists, cardiologist,
neurologist and surgeon would be referred if needed.
 Follow up as needed or any concerns
Tonsillitis
Seek medical help if your child has a sore throat for more than two days, trouble or
painful swallowing, weak, starts drooling or trouble breathing
Physical exam of throat, neck and lymph nodes
Rapid strep test or throat culture
Treatment is based on the cause such a virus, then there is no treatment. If its
bacterial such as strep then antibiotics will be needed.
Patient Education
1. Continue full course of antibiotics
2. Get plenty of rest
3. Drink plenty of fluids
4. Soft foods
5. Warm liquids or cold foods such as popsicles to soothe throat
6. Avoid cigarette smoking or around it to irritate the throat
7. Use humidifier
8. Gargle with saltwater
9. Use lozenge
10. Taking over the counter pain reliever such as acetaminophen
Referrals depends on the severity of the illness, if needed tonsillectomy
Follow up as needed or if any concerns
Rationale #1: My rationale for choosing Strep Pharyngitis is because he c/o throat pain,
painful swallowing and fever. He had positive swollen lymph nodes and had strep throat
as child multiple times.
Rationale #2: My rationale for choosing Infectious Mononucleosis is because the patient
c/o fever, sore throat and there are positive swollen lymph nodes noted, which are
prominent in Mono.
Rationale # 3: My rationale for choosing tonsillitis is because the patient complained of
sore throat with red swollen tonsils. He also c/o fever with white patches on his tonsils
and difficulty swallowing when he eats or drinks. His c/o are similar to what the
symptoms of tonsillitis are.
Reference:
Aronson, M., & Auwaerter, P. (2018). Infectious mononucleosis. In J. Mitty (Ed.),
UpToDate. Retrieved September 16, 2018, from
https://www.uptodate.com/contents/infectious-mononucleosis?search=infectious
%20mononucleosis&source=search_result&selectedTitle=1~150&usage_type=de
fault&display_rank=1
Busaba, N., & Doron, S. (2018). Tonsillectomy in adults: Indications. In L. Kunins (Ed.),
UpToDate. Retrieved September 16, 2018, from
https://www.uptodate.com/contents/tonsillectomy-in-adults-indications?
search=tonsillitis&source=search_result&selectedTitle=2~57&usage_type=defaul
t&display_rank=2
Pichichero, M., (2018). Treatment and prevention of streptococcal pharyngitis. In S.
Bond (Ed.), UpToDate. Retrieved September 16, 2018, from
https://www.uptodate.com/contents/treatment-and-prevention-of-streptococcalpharyngitis?search=strep
%20pharyngitis&source=search_result&selectedTitle=1~96&usage_type=default
&display_rank=1#H2187629545