SOAP Note
Subjective:
Jane is a 19-year-old college freshman who presents to the college health clinic with complaints of a sore throat, fever, fatigue, and body aches. These symptoms started abruptly yesterday. She denies having a cough, runny nose, sinus congestion, nausea/vomiting, or abdominal pain.
Objective:
Upon examination, Jane’s vital signs are within normal range with a blood pressure of 110/64, temperature of 101.6°F, heart rate of 88 beats per minute, and respiratory rate of 16 breaths per minute. Her eyes show no signs of abnormalities with normal pupillary response to light. Her sclera is clear, and her conjunctiva is pink without any discharge. The external ears appear normal, with clear ear canals bilaterally and no signs of swelling or exudate. The tympanic membranes (TMs) are pearly grey, and all landmarks are clearly visible. Jane’s nares are clear with no swelling, erythema, or discharge visible. Her pharynx is erythematous, and white tonsillar exudates are present bilaterally. She has tender swollen anterior cervical lymph nodes bilaterally.
Assessment:
Based on Jane’s symptoms and physical examination, her most likely diagnosis is acute pharyngitis. The erythematous pharynx, presence of white tonsillar exudates, and tender swollen cervical lymph nodes are consistent with this diagnosis. Her lack of cough, runny nose, and sinus congestion suggests that this is not primarily a viral upper respiratory infection.
Plan:
1. Treatment:
– Provide symptomatic relief: Recommend warm saline gargles, over-the-counter pain relievers such as acetaminophen or ibuprofen, and adequate hydration to alleviate the sore throat, fever, fatigue, and body aches.
– Rule out streptococcal infection: Perform a rapid antigen test or throat culture to determine if a group A Streptococcus (GAS) infection is present. If positive, initiate appropriate antibiotic therapy.
– Provide education: Explain the importance of completing the full course of antibiotics if streptococcal infection is confirmed, as well as the need for cough hygiene and good handwashing practices to prevent the spread of infection.
2. Follow-up:
– Schedule a follow-up appointment in 48-72 hours to assess the effectiveness of treatment and monitor for complications such as peritonsillar abscess or rheumatic fever.
3. Education:
– Discuss the importance of immunizations and recommend that Jane ensures her vaccinations are up to date, particularly for diseases such as influenza and meningitis, which can present with similar symptoms.
– Advise Jane to avoid close contact with others to prevent the spread of infection until she has been on appropriate antibiotic therapy for at least 24 hours.
– Provide information on the self-care measures she can take to alleviate her symptoms and prevent complications, such as adequate rest, avoiding irritants (e.g., smoking, alcohol), and maintaining good oral hygiene.
4. Differential Diagnosis:
– Although Jane’s symptoms are consistent with acute pharyngitis, it is important to consider other possibilities such as mononucleosis, influenza, or an allergic reaction. A monospot test or Epstein-Barr virus (EBV) serology may be considered if symptoms persist or worsen despite treatment for pharyngitis.
References:
1. Choby BA. Diagnosis and treatment of streptococcal pharyngitis. Am Fam Physician. 2009;79(5):383-390.
2. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for treatment of acute respiratory tract infections in adults: background, specific aims, and methods. Ann Intern Med. 2001;134(6):479-486.
3. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-e999.
4. Pichichero ME. Group A β-hemolytic streptococcus infections. Pediatrics in Review. 2018;39(7):341-355.
5. Van Buul LW, van der Wouden JC, Hondorp N, et al. Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev. 2014;2014(5):CD003968. doi:10.1002/14651858.CD003968.pub5.
