What is the appropriate SOAP note, including CPT and ICD‑10 codes, for a 15‑year‑old male presenting with sore throat, runny nose, fatigue, and right‑shoulder supraspinatus pain that worsens with pitching but not batting, with no fever, vomiting, or headache, and no past medical history or drug allergies?

SOAP Note for 15-Year-Old Male Baseball Pitcher

SUBJECTIVE

Chief Complaint: Sore throat and right shoulder pain

History of Present Illness:

• 15-year-old male select baseball pitcher presents with:
  • Throat symptoms: Sore throat, runny nose, fatigue; missed school today
  • Constitutional: No fever, no vomiting, no headache
  • Right shoulder pain: Localized to supraspinatus region
    • Pain specifically with throwing/pitching motions
    • No pain with batting
    • Currently using ice and muscle rub
    • Patient reluctant to rest arm per accompanying relative

Past Medical History: None
Medications: None
Allergies: NKDA
Social History: Active select baseball pitcher

OBJECTIVE

Vital Signs: [Document temperature, HR, BP, RR - assumed afebrile based on history]

Physical Examination:

HEENT: Tonsillopharyngeal examination findings [document presence/absence of erythema, exudate, lymphadenopathy]

Right Shoulder:

• Pain with arm extension and horizontal abduction
• Pain reproduced with overhead throwing motion
• [Document: ROM measurements, strength testing, specific impingement signs, scapular positioning]

ASSESSMENT

1. Acute pharyngitis, likely viral (J02.9) - Given absence of fever and constellation of upper respiratory symptoms (runny nose, fatigue)
2. Right shoulder rotator cuff tendinopathy/secondary impingement syndrome (M75.11) - Overuse injury in adolescent pitcher

PLAN

Pharyngitis Management:

Perform rapid antigen detection test (RADT) for Group A Streptococcus with throat culture backup if negative 1. Even without fever, bacterial pharyngitis must be excluded in adolescents. If negative, supportive care for viral pharyngitis (rest, fluids, analgesics as needed).

Shoulder Injury Management:

This 15-year-old pitcher has rotator cuff dysfunction from repetitive throwing stress and requires complete rest from throwing until asymptomatic 2. The supraspinatus pain with throwing but not batting, combined with pain on arm extension, is consistent with secondary impingement syndrome—the predominant shoulder pathology in adolescent pitchers due to rotator cuff weakness and glenohumeral microinstability 2.

Immediate interventions:

• Absolute cessation of all throwing activities until pain-free 2
• Continue ice application (cryotherapy)
• Consider NSAIDs for pain control if no contraindications
• Refer to sports medicine or orthopedics for comprehensive evaluation including:
  • Detailed ROM and strength assessment
  • Evaluation of scapular dyskinesis
  • Assessment of pitching mechanics with coach coordination 2
  • Consider imaging (radiographs initially; MRI if symptoms persist) 2

Rehabilitation protocol (1-3 months depending on severity) 2:

1. Acute phase: No throwing; focus on flexibility, posterior shoulder stretching, rotator cuff and scapular stabilizer strengthening
2. Intermediate phase: Progressive isotonic strengthening, core and lower extremity strengthening
3. Advanced phase: Plyometric program, short-distance throwing initiation
4. Return-to-throw phase: Progressive interval throwing program with proper mechanics emphasis

Return to pitching only after:

• Complete resolution of symptoms
• Pain-free ROM and strength restoration
• Successful completion of functional throwing program 2

Critical counseling points for patient and family:

• Continuing to pitch through pain risks permanent injury including rotator cuff tears (which do occur in adolescents) 2
• The mechanism is repetitive eccentric stress on supraspinatus and scapular stabilizers leading to fatigue and injury 2
• Early recognition and rest are essential to prevent chronic disability 2

Follow-up:

• Recheck pharyngitis: 48-72 hours if RADT/culture positive for treatment response
• Shoulder: 1-2 weeks to assess compliance with rest and initiate formal physical therapy referral

CPT CODES

• 99214 - Office visit, established patient, moderate complexity (or 99204 if new patient)
• 87880 - Streptococcus, group A, direct probe (RADT)
• 87081 - Culture, bacterial, throat (if RADT negative)

ICD-10 CODES

• J02.9 - Acute pharyngitis, unspecified (change to J02.0 if strep positive)
• M75.11 - Rotator cuff syndrome of right shoulder (or M75.81 for other shoulder tendinitis if more specific)
• Z79.899 - Other long-term (current) drug therapy (if prescribing NSAIDs)

Common pitfall: The family's resistance to rest is a major barrier. Emphasize that throwing through pain in a 15-year-old pitcher can cause permanent damage requiring surgery, versus 1-3 months of proper rehabilitation allowing full return to sport 2.