Sore Throat / Strep

SOAP Note

Subjective (S)

CC: Sore throat x 2 days HPI: 19 y/o male with acute pharyngitis. 7/10 pain with swallowing. Fever 101.5°F. Anterior cervical lymphadenopathy. Denies cough, rash.

Objective (O)

Vitals: BP 118/72, HR 88, Temp 101.2°F Pharynx: Erythematous, tonsillar exudates, tonsils 3+ bilaterally Neck: Tender anterior cervical LAD Centor Score: 4/4 Rapid Strep: POSITIVE

Assessment (A)

Primary Dx: Acute Pharyngitis, Group A Strep High Centor score, classic presentation, positive rapid strep.

Plan (P)

1. Amoxicillin 500mg TID x 10 days 2. Ibuprofen 400mg q6h PRN Education: Complete antibiotics, contagious until 24h on treatment Return if: Difficulty breathing/swallowing