What is the treatment plan for a patient with a 6-day history of cold symptoms, now presenting with sore throat, voice hoarseness, dry cough with scant blood in sputum, 3 white spots on tonsils, and cervical lymphadenopathy (cervical lymph node enlargement)?

SOAP Note Plan: Suspected Group A Streptococcal Pharyngitis

Assessment

This patient requires immediate testing for Group A Streptococcus (GAS) with rapid antigen detection test (RADT) or throat culture, as the clinical presentation strongly suggests bacterial pharyngitis despite the presence of cough. 1

Clinical Features Analysis

• Modified Centor Score = 3-4 criteria present: 2, 3

  • Fever (present on day 1) 2
  • Tonsillar exudates (3 white spots on tonsils) 2
  • Tender anterior cervical lymphadenopathy (present) 2
  • Cough present (typically argues against GAS, but does not exclude it) 2

• Concerning features requiring attention: 4

  • Hemoptysis (scant blood in sputum) - monitor for progression
  • Voice hoarseness - assess for airway involvement
  • Duration of 6 days - longer than typical viral pharyngitis

Diagnostic Plan

1. Perform RADT immediately - has ≥95% specificity for GAS 5
2. If RADT negative: Obtain throat culture for confirmation given high clinical suspicion (3+ Centor criteria) 1, 2
3. Do not prescribe antibiotics empirically - await test confirmation 2

Treatment Plan

If GAS Testing Positive:

First-line antibiotic therapy (choose one): 1

• Penicillin V: 500 mg PO twice daily × 10 days (preferred due to proven efficacy, narrow spectrum, no resistance, and low cost) 1

  • Alternative: 250 mg PO 4 times daily × 10 days 1

• Amoxicillin: 1000 mg PO once daily × 10 days (equally effective, more palatable, improves compliance) 1, 6

  • Alternative: 500 mg PO twice daily × 10 days 1

For penicillin allergy (non-anaphylactic): 1

• Cephalexin: 500 mg PO twice daily × 10 days 1
• Cefadroxil: 1 g PO once daily × 10 days 1

For penicillin allergy (anaphylactic/immediate hypersensitivity): 1

• Clindamycin: 300 mg PO three times daily × 10 days 1
• Azithromycin: 500 mg PO once daily × 5 days (note: significant geographic resistance exists) 1, 7

Symptomatic Management (regardless of antibiotic decision):

• Ibuprofen or acetaminophen for pain and fever control 2, 5
• Throat lozenges for additional relief 2
• Adequate hydration 5
• Reassure that symptoms typically resolve within 1 week 2

Monitoring & Follow-up

Red Flags Requiring Urgent Re-evaluation: 4

• Worsening symptoms after 48-72 hours of appropriate antibiotics 7
• Symptoms persisting >5 days after starting treatment 7
• Development of: 4
  • Unilateral tonsillar swelling or uvular deviation (peritonsillar abscess)
  • Severe dysphagia, drooling, or respiratory distress (epiglottitis)
  • Neck stiffness or swelling (retropharyngeal abscess)
  • Trismus or "hot potato voice" (peritonsillar abscess)

Hemoptysis Monitoring:

• Scant blood in sputum is likely from pharyngeal irritation but requires monitoring for progression 4
• If hemoptysis worsens or becomes more than blood-streaked sputum, consider chest imaging to rule out pneumonia

Important Caveats:

• Do NOT retest after completing antibiotic course unless patient is symptomatic 1
• Do NOT test or treat asymptomatic household contacts 1
• The 10-day duration is critical for pharyngeal eradication of GAS and prevention of acute rheumatic fever 1
• Shorter courses with other antibiotics are NOT recommended despite some data suggesting efficacy 1

Patient Education:

• Antibiotics shorten symptom duration by only 1-2 days 5
• Primary benefit is prevention of acute rheumatic fever and suppurative complications (peritonsillar abscess, cervical lymphadenitis) 1
• Patient becomes non-contagious within 24 hours of starting antibiotics 1
• Can return to usual activities once afebrile and after 24 hours of antibiotics 1