SOAP Note 1 Comprehensive SOAP on Pediatrics HEENT

Running head: STREPTOCOCCAL PHARYNGITIS 1

First Name, Last Name

Florida International University

Professor

Date

STREPTOCOCCAL PHARYNGITIS 2

Subjective

Initials of Patient: C.T

Patient Age: 8 years old

Patient Gender: Female

Patient Ethnicity: American-Haitian

Source of information: Patient’s mother and patient, reliable

Chief Complaint: Sudden onset of sore throat started this morning, cough, fever started 2 days,

and feeling malaise

History of Present Illness:

C.T. is a 8-year old female who presents today accompanied by her mother due to sudden

onset of sore throat, a recent fever, a cough, and feeling malaise. The mother reports that the

child has been sick for about two days, the child started with a fever of 101.0 and a non-

productive cough. For the fever, she has been giving the child Tylenol which helps in reducing the

fever and the child’s max temperature was 101.5. The mother verbalize that the child woke up

this morning with complaining of severe sore throat and the child complains of pain with

swallowing. The mother states that she can see the child’s throat is red and irritated. She had the

child gargle with some warm salt water which did not help. In addition, she verbalized a decrease

in the child’s appetite for about 2 days.

Past Medical History:

Unremarkable

Past Surgical History:

None

Family History:

STREPTOCOCCAL PHARYNGITIS 3

Mother, 34 years old, alive, unremarkable

Father, 36 years old, alive, HTN

Brother 3 years old, alive, unremarkable

Maternal Grandmother 62 years old, alive, no health issues

Maternal Grandfather 65 years old, alive, Type 2 Diabetes mellitus, Hyperlipidemia

Paternal Grandmother 66 years old), alive, Type 2 Diabetes mellitus, HTN

Paternal Grandfather 70 years old, alive, HTN

Social History:

C.T. is well develop and well-nourish 8 year old girl. She is fully immunized. C.T. lives

with both parents. Her mother is a teacher at a local elementary school. Her father is a real

estate agent. The maternal set of grandparents live nearby and visit the children on often. C.T.

enjoys playing with her little brother after school and she in gymnastic after school. She often

visits her grandparents during the weekends. She loves to play outdoors and riding her bicycle

Medications Taken at home:

Medication Name Indication

Acetaminophen 1 tsp po every 4-6 hours PRN for fever

Allergies:

No known drug or food allergies.

Immunizations:

Immunizations: (vaccine & date given) – Patient is up-to-date on all immunizations as per CDC

Birth- HepB

2 months - HepB, DTaP, Hib, IPV, PCV, RV given (11/02/2010)

STREPTOCOCCAL PHARYNGITIS 4

4 months - DtaP, Hib, IPV, PCV, RV given (01/06/2011)

6 months - HepB, DtaP, Hib, IPV, PCV, RV given (03/04/2011)

12 months - Hib, PCV, Varicella, MMR, HepA given (09/05/2011)

16 months - DtaP, Influenza given (01/05/2012)

18 months - HepA given (04/06/2012)

28 months - Influenza given (02/07/2013)

40 months - Influenza given (02/06/2014)

48 months - DtaP IPV, MMR, Varicella given (12/05/2014)

Review of Systems:

General:

Integumentary:

Recent fever, fatigue, and malaise. Denies weight loss or poor weight

gain.

Denies any rash. Denies itchiness, no bruises or lesions.

Neurological: Denies dizziness, loss of consciousness, or seizure activity, numbness

or tingling.

Head:

Eyes:

Ears:

Nose/Mouth/Throat:

Normocephalic. Denies any hair loss, no lesions.

Denies any blurred vision, no difficulty focusing, vision 20/20.

Denies any ear pain, hearing loss, ringing in ears, discharge.

Positive for sore throat, swollen glands, and redness to pharynx.

Denies nose bleed, dysphagia, hoarseness, or nasal congestion.

Cardio: Denies chest pain, no palpitations or peripheral edema.

Respiratory: Non-productive cough. Denies shortness of breath, wheezing or night

sweats.

STREPTOCOCCAL PHARYNGITIS 5

GI: Decrease appetite for the past 2 days. Patient denies abdominal pain,

nausea, vomiting, or change in stool pattern or color.

GU: Denies dysuria, urgency, frequency, hematuria or suprapubic pain.

Musculoskeletal:

Developmental:

Milestone

Behavior/Psychiatric:

Patient denies muscle or joint pain, paralysis, or ataxia.

C.T. is in third grade gifted program. She can bathe and dress herself,

and brush her teeth independently. She enjoys gymnastic, singing, and

reading story books.

Denies any mood swings, tantrums, behavioral disorders, sleeping

problems, psychotic disorders, or mental health problems.

Objective

Vital Signs and Other Measurements:

Age Gender Ethnicity Height Weight BMI

8 years old Female American-

Haitian

54

inches

65 lbs 9.8%

Temp HR BP RR O2Sat

102 F 98 100/54 24 98%

Physical Exam:

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General: Patient is alert and calm, is properly dressed and appears well-

nourished. No signs of acute distress. Her BMI is in the 47th

percentile. There are no concerns for abuse.

Neurological: Patient is alert & oriented x 4. Cranial nerves II-XII grossly intact,

has normal speech, no difficulty in concentration. Muscle tone and

reflexes appear normal. All deep tendon reflexes 2+, no focal

deficits.

Head:

Eyes:

Ears:

Nose:

Throat/Mouth:

Head and characteristic facies symmetry noted. Hair distribution

even.

PERRLA. Corneal light reflex and red reflex present. No strabismus.

Canals patent, TM’s are normal. No purulent drainage noted.

Nares symmetrical. Nasal mucosa with no inflammation, normal

appearing turbinate.

Pharynx is severely erythematous with +2 tonsils outside of the

pillars with white exudates. Submandibular glands are tender to

touch, palatal petechia noted.

Neck: Anterior cervical lymphadenopathy present. Trachea midline. Neck

supple with full ROM.

Lungs: RR: 24. O2 sat: 98% on room air. Breaths are regular and unlabored.

Chest movement is symmetrical. Clear breath sounds bilaterally in all

lobes.

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Cardio: HR: 98. S1 and S2 present, with normal rhythm and rate. No heart

murmurs, S3, or S4 noted. BP: 100/54. Capillary refill within normal

limits. No peripheral edema. Radial and pedal pulses +2.

GI: Abdomen is soft without organomegaly. Bowel sounds present x 4

quadrants. No masses, no rebound tenderness. No distention noted.

GU: Bladder is non-distended. No costovertebral angle tenderness noted.

Musculoskeletal: Spine is straight with no scoliosis or kyphosis noted. Full ROM

against gravity with full resistance in all extremities noted. No

edema, ecchymosis or erythema noted.

Integumentary: Skin texture is warm, smooth, and soft. No lesions, no rash, no

bruising or scars noted. Capillary refill less than 2 seconds.

Behavior/Psychiatric: Alert and oriented. No distress. Behavior appropriate for age.

Exams:

Rapid strep swab administered in the office, the test is positive (sent for culture).

The gold standard for diagnosing group A beta-hemolytic streptococcal

(GABHS) pharyngitis is a throat swab culture. The sensitivity is 90% to 95%

but results are delayed. The Rapid Antigen Detection Test (RADT) yields

results in minutes (Borchardt, 2013).

Assessment

Current Diagnosis: Streptococcal Pharyngitis

Differential Diagnoses:

STREPTOCOCCAL PHARYNGITIS 8

1. Upper respiratory infection (URI)

2. Influenza

3. Viral Pharyngitis

Plan

1. Amoxicillin (400mg/5ml) 5ml PO every 12 hours x 10 days # 200ml no refills as per

Epocrates, weight dosing at 40mg/kg per day.

2. Use acetaminophen or ibuprofen to treat pain and fever as ordered.

3. No vaccines administered this visit. Parent counseled on yearly influenza vaccinations

and on the next set of recommended vaccinations due at ages 11-12 per CDC guidelines

(CDC, 2017). Strep swab sent for culture for pyrogenic types of strep and parent to be

notified if positive. It will not change treatment plan.

4. Complete antibiotics for full course even if symptoms disappear. Strep throat will be

contagious until 24 hours of antibiotic use. Avoid sharing personal items with other

siblings or household members, change toothbrush out in 36 hours. Adequate and

frequent hand washing to avoid transmission of virus to others. Drink plenty of fluids to

avoid dehydration. Return to school once fever free for at least 24 hours (Ferri, 2016).

5. Be sure that the patient gets plenty of rest and increase activity as tolerated. Warm salt

gargles for sore throat. Ensure that the patient drinks 6-8 glasses of water daily to stay

hydrated and increase intake of fluids with a fever. Be sure that the patient eats a

nutritious diet (Cash & Glass, 2014).

6. Preventive Care: Diet appropriate for child age, healthy eating habits, focus in school, no

arguing in the presence of the child. Safety: helmet, seat belt, no gun in the house, no

STREPTOCOCCAL PHARYNGITIS 9

smoking, stay active, adequate nutrition, fresh food and fruit, listen to parents and

teachers, be respectful.

Subjective Analysis

Streptococcal Pharyngitis, also known as strep throat is a bacterial infection caused by

Streptococcus pyogenes, also known as group A streptococcus. Group A streptococci (GAS) are

gram-positive bacteria which cause acute pharyngitis and is accountable for about 20-30% of

sore throat cases in children (Martin, 2015). GABHS pharyngitis is usually associated with

painful cervical adenopathy, chills, high fever, pharyngeal exudate, scarlatiniform rash, and

headache. While viral pharyngitis is accompanied by symptoms of cough, sneezing hoarseness,

and rhinorrhea (Martin, 2015).

Streptococcal bacteria are highly contagious. They can spread through airborne droplets

when someone with the infection sneezes or coughs, also through shared drinks or foods. In

addition, the bacteria can be transmitted through surfaces such as a doorknob or other surfaces

and one can transfer the bacteria through your mucous membranes. GAS pharyngitis is very

common amongst school-age children around the winter and spring time. Elementary school

children often develop one to three new streptococcal infections each school year (Martin,

2015). Furthermore, it is most commonly found in ages 5 years to 15 years old children. In

C.T.’s scenario, she is complaining of sudden onset of sore throat, fever, pain with swallowing,

and generalized malaise. These symptoms point to streptococcal pharyngitis.

Objective Analysis

Upon physical exam, C.T. has a fever of 102, her tonsils size are 2+ with an overlying

white exudate and her throat is erythematous. In addition, C.T. has tender anterior cervical

STREPTOCOCCAL PHARYNGITIS 10

lymphadenopathy and palatal petechia. About 50% of children with Streptococcal pharyngitis

have tender and enlarged cervical lymph nodes (Martin, 2015). Furthermore, 25% of cases of

streptococcal pharyngitis, the tonsils and pharynx may appear erythematous with

exudate (Martin, 2015). The history and physical examination solely cannot discern between

streptococcal pharyngitis versus an infection due to other causes. Laboratory confirmation is the

accurate method of making a diagnosis of GAS. In cases where GAS is suspected, it is essential

to obtain a rapid antigen test by swabbing the surface of the tonsils and posterior pharynx and

send the culture, which is the gold standard testing for GAS. Although the rapid antigen test has

a specificity of greater than 95%, the sensitivity of the test depends on the method used and that

is why a throat culture should be done to assess for GAS (Martin, 2015).

Assessment Analysis

The differential diagnoses for this patient are an upper respiratory infection (URI),

influenza, and viral pharyngitis. In upper respiratory infection, which is a viral infection, the

usual presenting symptoms include nasal congestion, headache, rhinorrhea, cough, and fever.

With GABHS, the patient can also have symptoms of fever and headache, however nasal

congestion, cough, and rhinorrhea are uncommon (Burns et al., 2017). In addition, with URI no

antibiotics are required and symptoms usually decrease or resolved in 7-10 days. With influenza,

the patient can present with similar symptoms that may resemble GABHS which are malaise,

fever, and sore throat. In C.T. case, the sudden onset of severe sore throat yields more towards

GABHS versus influenza. Another differential diagnosis would be viral pharyngitis. When a

patient is presented with a sore throat it can be difficult to differentiate between viral and

bacterial causes (Burns et al., 2017). However, symptoms with a cough, conjunctivitis,

STREPTOCOCCAL PHARYNGITIS 11

rhinorrhea, and hoarseness are usually presented with viral pharyngitis instead of streptococcal

pharyngitis.

Plan Analysis

Antibiotic treatment is the first line of treatment for patients with streptococcal

pharyngitis who are symptomatic and test positive for GABHS. The patient should be treated

with an antibiotic that is sensitive to GAS. Antibiotics have shown to be effective in reducing

symptoms, prevent the spread to others and reduce the risk of developing complications such

as rheumatic fever, acute glomerulonephritis, and post-streptococcal reactive arthritis (Burns et

al., 2017).

Streptococcus pyogenes (Group A streptococcus), the bacteria that causes strep throat

have remained sensitive to penicillin and overall when treating a bacterial infection, it is

desirable to use the most narrow-spectrum antibiotic that will treat the infection. Penicillin is a

narrow spectrum antibiotic which is a good option since it is well tolerated, has minimal side

effects, is not expensive, and has proven to be effective in treating streptococcal pharyngitis

(Burns et al., 2017). However, in treating children with GABHS, amoxicillin is frequently

substituted for penicillin for a more pleasant taste in liquid suspension and the efficacy is equal

to penicillin.

Supportive care such as antipyretic Acetaminophen, fluids, and rest are also

recommended. Noncompliance with the full course of antibiotic treatment can lead to treatment

failure and its vital that patient complete full course of antibiotic even though symptoms have

resolved. In addition, the patient's toothbrush should be discarded within 24 hours after the use of

antibiotics (Burns et al., 2017). Personal items should not be shared with siblings or household

members. The child can return to school after 24 hours after taking antibiotics and is afebrile.

STREPTOCOCCAL PHARYNGITIS 12

Culture Components

C.T. is Haitian-American and was born and raised in Boynton Beach, Florida. Her father

is White American and mother is Haitian. C.T. mostly speaks English with a few words of

Creole. C. T’s parent follows the Western cultural tradition since they reside in the United States

most of the lives. They have a strong family relationship and are Christians. In America, most

religions are practiced which is originated on the basis of religious freedom, however, most

Americans are Christians (Zimmermann, 2017). Although certain foods such as hamburgers,

potato chips, macaroni and cheese, and meatloaf are commonly considered American dishes, C.

T.’s family practice healthy eating habits which consist of heart-healthy foods. In addition, they

practice preventive care, good health habits such as staying physically active and managing

stress effectively. Western culture refers mainly to the United States and Europe (Zimmermann,

2017). With the United States becoming more diverse, the U.S. is referred to as the “melting pot”

at times in which various cultures have contributed to their own diversity of flavors to the

American culture (Zimmermann, 2017).

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References

Borchardt, R. A. (2013). Diagnosis and management of group A beta-hemolytic streptococcal

pharyngitis. Journal of the American Academy of Physician Assistants, 26(9), 53-54.

doi:10.1097/01.JAA.0000433876.39648.52

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L. (2017).

Pediatric primary care. (6th ed.). St. Louis, MI: Elsevier.

Cash, J. C., & Glass, C. A. (2014). Family practice guidelines. (3rd ed.). New York, NY:

Springer Publishing Company, LLC.

Center for Disease Control and Prevention. (2017). Recommended immunization schedule for

children and adolescents aged 18 and younger, United States, 2017. Retrieved from

https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-combined-

schedule.pdf

Ferri, F. F. (2016). Ferris clinical advisor: 5 books in 1. Philadelphia, PA: Elsevier.

Martin, J. M. (2015). The mysteries of streptococcal pharyngitis. Current Treat Options

Pediatric, 1(2): 180–189. doi:10.1007/s40746-015-0013-9.

Zimmermann, K. A. (2017). American culture: Traditions and customs of the United States.

Retrieved from https://www.livescience.com/28945-american-culture.html.

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