Running head: FINAL ASSESSMENT SOAP NOTE 1

Name: Erika Payne

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Subjective Information

Identification (ID):

Date of visit: 4/2/19

Initials: J.L.

Age: 5 years

DOB: 1/1/14

Gender: Male

Advanced directives: No

Insurance: Blue Cross Blue Shield

Ethnicity: Caucasian

Source: Mother, reliable

Chief Complaint:

“Sore throat for 3 days.”

History of Present Illness (HPI):

J.L. is a 5-year-old, Caucasian male who is accompanied by his mother. J.L. presents for

evaluation of a sore throat x3 days. Mother reports patient has also complained of a stomachache

and headache x3 days. Denies aggravating, alleviating, or temporal factors. J.L. had a

temperature of 101F orally at home last night that was relieved with a dose of acetaminophen.

Mother reports he woke up this morning with a rash on the right side of his chest. Denies

spreading of rash or notice of itching. Mother reports patient has had a decreased appetite and
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decreased fluid intake since onset of symptoms. He consumed pudding last night. Patient has

decreased activity and “hasn’t felt like playing outside” per mother. Denies runny nose, cough,

pulling on ears, nausea, vomiting, diarrhea, or constipation. Denies similar symptoms in the past

or history of strep throat. Sick contacts at school, but mother is unsure of their condition.

Past Medical History (PMH):

General health: Good

Surgeries: None

Past Illnesses: Recurrent otitis media

Hospitalizations: None

Past Medical Problems:

Neurologic: Denies history of seizures or tremors.

HEENT: Denies allergic rhinitis and recurrent sinusitis. History of recurrent otitis media – did

not need to have tympanostomy tubes.

Respiratory: Denies history of asthma, pneumonia, COPD, sleep apnea, or bronchitis.

Cardiovascular: Denies history of hypertension, hyperlipidemia, or cardiac events.

Musculoskeletal: Denies history of arthritis or fibromyalgia.

Endocrine: Denies history of thyroid disorders or diabetes.

Dermatologic: Denies history of psoriasis, atopic dermatitis, rosacea, skin cancer, and urticaria.

Gastrointestinal: Denies history of gastroesophageal reflux disease or inflammatory bowel

disorders.

Genitourinary: Denies history of kidney stones, bladder infections, or kidney disease.

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Psychiatric: Denies history of depression, anxiety, attention deficit disorder, insomnia, or mood

disorders.

Immunizations: Immunizations are up to date. Received flu vaccine last fall (in September or

October per mother)

Health Maintenance:

Last PE: Mother unsure.

Diagnostic tests: No recent tests

Specialists: None

Social History:

Personal History:
Marital status: Single

Sexual orientation: Deferred

Religious preferences: Deferred

Occupation: Student

Safety or abuse issues: None

Health Habits:

Tobacco use: None. Patient exposed to second hand smoke in the home (father smokes)

Alcohol use: None

Drinks per day: None

Illicit drugs: None

Diet: Decreased appetite per mother. Consumed pudding last night.

Exercise: Decreased activity per mother. Pt not wanting to play outside which is abnormal.

Exposure to toxins: None

Sexual history: None

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Family History:

Mother, good health, living

Father, good health, living

Brother, seasonal allergies, living

Maternal grandmother, high cholesterol, living

Maternal grandfather, heart disease, living

Medications:

Denies use of prescription medications, vitamins, supplements, or herbal preparations. Mother

administered one dose of OTC acetaminophen last night for fever.

Allergies:

No known drug allergies. Denies allergy to food, latex, or stinging insects.

Review of Systems (ROS):

General:

Mother reports patient “looks tired” and hasn’t felt like playing outside, which is abnormal.

Diet:

Reports poor appetite and decreased fluid intake. Consumed pudding last night.

Skin, Hair, & Nails :

Reports red rash to right chest that started this morning. No spreading noted. No drainage.

Mother reports patient has not complained of itchiness or pain from rash. Denies any other

changes to skin, hair, or nails.

Head and Neck:

Reports mild headache x3 days.

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Eyes:

Denies vision disturbances, dry eye, watery eyes, discharge, use of glasses or contacts, and

trauma.

Ears:

Denies hearing loss, otalgia, discharge, or tinnitus.

Nose:

Denies nasal congestion, epistaxis, postnasal drip, or sneezing.

Throat and Mouth:

Complains of sore throat x3 days. No aggravating or alleviating factors noted. No temporal

factors.

Lymph:

Denies lymph node tenderness or enlargement.

Chest and Lungs:

Denies cough, shortness of breath, dyspnea on exertion, wheezing, or night sweats.

Cardiovascular:

Denies chest pain, palpitations, edema, claudication, exercise intolerance, varicosities, or

syncope.

Gastrointestinal:

Denies nausea, vomiting, or diarrhea.

Musculoskeletal:

Denies weakness, heat, swelling, and changes in range of motion.

Neurologic:

Denies loss of coordination, numbness, or tingling.

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Objective Information:

Physical Exam:

Vital Signs:

Temperature: 102F orally

Heart Rate: 110

Respirations: 18

BP: 92/60

Height: 40 inches

Weight: 40 lbs

BMI: 17.6% (92nd percentile)

Pain Scale: Pediatric Faces Pain Scale – 6/10

Focused exam:

General Appearance

Patient is a 5-year-old male who is well groomed, dressed appropriately for season, and

cooperative. He is alert, but ill appearing. Patient listening to mother answer questions.

Mental Status and Neurological

Oriented to person, place, and time. Speech is clear and understandable. Cranial nerves II-XII

grossly intact. Sensory and motor function intact. Deep tendon reflexes are 2+ in bilateral biceps,

triceps, knee, and Achilles.

Skin/Hair/Nails

Skin is fair with no cyanosis present. Skin turgor is elastic. He has an erythematous

maculopapular rash that extends from bilateral chest to bilateral upper arms, lower neck, and

back. Rash blanches with palpation. Rash is non-tender to palpation. Skin that is not affected by
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rash is fair in color and soft. Hair is blonde, dry, and soft. Nails are trimmed with no cracking,

splitting, or discoloration. Nail beds are pink, capillary refill is < 3 seconds, and no evidence of

clubbing of the fingers is noted.

Head

Head is normocephalic with no signs of trauma. No masses or tenderness noted on palpation.

Neck

No jugular vein distention noted. No bruits noted on auscultation of the carotid arteries. Trachea

is midline and freely mobile. Neck is supple with full range of motion. Thyroid gland is not

palpable. Bilateral tonsillar lymph nodes are swollen, 1cm in size, and tender to palpation. No

swelling of preauricular, post auricular, occipital, submaxillary, submental, anterior cervical

chain, or posterior cervical chain.

Eyes

Pupils are equal, round, and reactive to light and accommodation. Conjunctiva is pink and sclera

are white. Extraocular movements intact. Upon fundoscopic exam, red light reflex is present in

both eyes, disc margins are sharp, vasculature is normal, and a normal cup-disc ratio is present.

Ears

Ears are symmetrical. Pinna is in line with the outer canthus of the eyes bilaterally. Ear canals

are pink bilaterally. Tympanic membranes are pearly, gray with cone of light present bilaterally.

No cerumen present.

Nose

Mucosa is pink without discharge and non-edematous. Nasal septum appears midline. No

tenderness noted upon palpation of frontal and maxillary sinuses. Nares are patent, no erythema,

Mouth and Throat

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Lips are pink and moist. Dentition is intact with no obvious caries. Buccal membranes are pink

and moist. Tongue is pink, midline, and moist. Pharynx is erythematous. Soft palate with

petechiae. No exudate present. Tonsils are 2+. Uvula adhered to right tonsil, rise with “ahhh” is

intact. Gag reflex intact.

Chest and Lungs

Chest is symmetrical in shape. Symmetrical, bilateral movement of chest expansion. 18

respirations per minute. No visible use of accessory muscles. No crepitus, masses, lesions, noted

to anterior or posterior chest. Clear auscultated lung sounds throughout anterior and posterior

lung fields bilaterally. No wheezes, crackles, rubs or rhonchi.

Heart/Peripheral Vascular

No signs of acute distress. PMI is palpable at the left midclavicular line at the 5th intercostal

space. No heaves, lifts, thrills or thrusts at PMI. S1 and S2 are audible with regular rhythm. Heart

rate of 110. No splitting, gallops, rubs, murmurs or snaps at the five cardiac points of

auscultation. All pulses 2+ bilaterally. No cyanosis or edema throughout body.

Abdomen

Abdomen is flat and symmetrical. Skin is fair in color. No rash noted. No masses, pulses, or

peristalsis visible. Abdomen soft to light and deep palpation. Active bowel sounds in all 4

quadrants. No scars, visible venous pattern, or striae of the abdomen. No visible pulsation or

peristalsis. No aortic, renal, iliac or femoral bruits. Inguinal lymph nodes not palpable or

enlarged.

Musculoskeletal

Patient is able to walk around room and get on to the exam table without difficulty. Joints are

symmetrical bilaterally. No unusual skin markings, ecchymosis, erythema, or changes in the skin
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integrity. No guarding, discoloration, pallor, cyanosis or bleeding in joints throughout. No

warmth, clicking or crepitus of joints. No edema, spasms, masses, atrophy, hypertrophy,

increased tone irregularities noted in any muscle groups bilaterally.

Diagnostic Tests or Labs:

Rapid Antigen Detection Test - Positive

Throat Culture – Pending

Assessment Information:

Differentials:

Scarlet fever, uncomplicated A38.9

Streptococcal pharyngitis J02.0

Acute pharyngitis due to other specified organisms J02.8

Rationale:

Differential diagnosis for this patient includes scarlet fever, streptococcal pharyngitis, and

acute pharyngitis due to other specified organisms. Due to the patient’s report of a sore throat,

headache, fever, absence of a cough, and the results of the physical examination, he most likely

has streptococcal pharyngitis. However, due to the new onset of the blanchable rash to the trunk,

the best diagnosis is scarlet fever. It is likely that the patient has streptococcal pharyngitis that

has progress to scarlet fever as evidenced by the characteristic scarlatiniform rash (Burns et al.,

2017). Acute pharyngitis due to other specified organisms is a possible diagnosis, but less likely

due to absence of common viral symptoms (CDC, 2018).

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Scarlet fever is a bacterial illness that can develop in children who have streptococcal

pharyngitis (CDC, 2018). This occurs when the bacteria release a toxin that causes a

characteristic diffuse erythematous rash that may feel like sandpaper (CDC, 2018). The rash

usually appears approximately two days after the illness begins which is consistent with the

mother’s report (CDC, 2018). The diagnosis of scarlet fever is based on clinical manifestations, a

rapid antigen detection test (RADT), and throat culture.

The Centor criteria utilizes specific criteria including absence of cough, swollen and

tender anterior cervical lymph nodes, temperature >100.4F, and tonsillar exudate or swelling to

determine the probably that a patient has streptococcal pharyngitis (Choby, 2009). Age is also

considered (Choby, 2009). Using the Centor system, J.L. scored four points (Choby, 2009). This

indicates he has a high probability of streptococcal pharyngitis based on symptoms and should

receive treatment (Choby, 2009). The algorithm indicates empiric antibiotic treatment can be

considered, however, due to the increase in antibiotic resistance it is best to perform a rapid strep

test and throat culture to verify (Choby, 2009). Due to the positive rapid antigen test for

streptococcal pharyngitis and the presence of the characteristic rash, the best diagnosis is scarlet

fever (CDC, 2018). The treatment of scarlet fever is the same as streptococcal pharyngitis (CDC,

2018).

Streptococcal pharyngitis is usually caused by group A streptococcus, also known as

Streptococcus pyogenes (Pichichero, 2019). This type of infection is common in children

between ages of 5 and 15 years old, especially during the winter and early spring (Ward, 2019).

Symptoms of streptococcal pharyngitis include sore throat, fever, headache, abdominal pain,

nausea, and vomiting (Ward, 2019). These complaints are consistent with the report from J.L.’s

mother. Streptococcal pharyngitis can cause petechiae on the soft palate or pharynx, a swollen
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red uvula, enlarged tonsillar tissue, tonsillopharyngeal exudate, tender and enlarged anterior

cervical lymph nodes, or bad breath on physical examination (Burns et al., 2017). A patient with

streptococcal pharyngitis should have an absence of symptoms of a viral infection including a

cough, runny nose, conjunctivitis, hoarseness, or diarrhea (Ward, 2019). Diagnosis for

streptococcal pharyngitis is based on clinical manifestations and diagnostic testing including a

rapid antigen detection test and throat culture (Ward, 2019). The patient meets diagnostic criteria

for streptococcal pharyngitis, but his illness has progressed to become scarlet fever.

Ward (2019) reports that viruses are the most common cause of acute pharyngitis. It is

possible that the patient may be suffering from an acute pharyngitis due to other specified

organisms, such as a viral infection. A viral infection would most likely present with additional

symptoms including runny nose, cough, conjunctivitis, hoarseness, or diarrhea (Ward, 2019).

The patient did not exhibit symptoms associated with a viral infection. In addition, he tested

positive on the rapid antigen test for streptococcal pharyngitis, thus, acute pharyngitis due to

other specified organisms can be ruled out.

DIAGNOSES:

ICD 10 codes:

Scarlet fever, uncomplicated A38.9

Plan:

Prescriptions:

Amoxicillin suspension (250mg/5ml)

Take 9ml by mouth twice a day for 10 days. No refills. Dispense: 180ml
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Children’s Acetaminophen Suspension (160mg/5ml)

Take 7.5ml by mouth every 4 to 6 hours as needed for pain or fever. Do not administer

more than five doses per day. No refills. Dispense: 120ml

Educate that J.L. can return to school when he is afebrile and has been taking the antibiotics for

at least 24 hours (Burns et al., 2017). Educate that J.L. must complete the entire prescription for

the antibiotic even if symptoms have improved (Burns et al., 2017). Recommend supportive care

including rest, fluids, and soft foods such as pudding or applesauce to sooth his sore throat

(Burns et al., 2017). Educate the patient to discard his toothbrush or bathroom cup as this can

harbor bacteria (Burns et al., 2017). It is important to inform the patient and mother that as the

rash fades, the skin may peel around the fingers, toes, or groin area, but this is expected (CDC,

2018). J.L. should not be exposed to second hand smoke as this is harmful to his health.

Encourage hand hygiene to prevent the spread of infection (Burns et al., 2017). Inform the

mother that the treatment plan may change depending on the results of the throat culture, but she

will be notified. J.L. should follow up in 3 days if symptoms don’t improve or new symptoms

arise.

CPT Codes:

99204 – Office/Op Visit, New PT, 3 Key Components: Comprehensive Hx; Comprehensive

Exam; Med Decision Moderate Complexity

87880 – Infectious agent antigen detection

87070 – Culture, bacterial isolation and presumptive identification

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References

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, MO: Elsevier

Centers for Disease Control and Prevention. (2018). Group A Streptococcal (GAS) Disease.

Retrieved from https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html

Choby, B.A. (2009). Diagnosis and Treatment of Streptococcal Pharyngitis. American Family

Physician. Retrieved from https://www.aafp.org/afp/2009/0301/p383.html

Pichichero, M. (2019). Complications of streptococcal tonsillopharyngitis. UpToDate. Retrieved

from

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Wald, E.R. (2019). Group A streptococcal tonsillopharyngitis in children and adolescents:

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