What elements should be documented in a SOAP note for a pediatric patient presenting with sore throat?

SOAP Note Documentation for Pediatric Sore Throat

A SOAP note for a child with sore throat must systematically document clinical features that distinguish Group A streptococcal pharyngitis from viral causes, guide appropriate testing decisions, and justify antibiotic use only when indicated.

Subjective Section

Document the following specific elements to stratify infection probability:

• Onset and timing: Sudden versus gradual onset of symptoms 1
• Primary symptoms: Severity of throat pain, pain with swallowing, and presence/absence of fever 1
• Associated symptoms suggesting viral etiology: Cough, rhinorrhea (coryza), hoarseness, conjunctivitis, diarrhea, or presence of oral ulcers 1, 2
• Associated symptoms suggesting bacterial etiology: Headache, nausea, vomiting, abdominal pain (especially in children) 1
• Epidemiological factors: Age of child, season (winter/early spring increases streptococcal likelihood), known exposure to documented streptococcal pharyngitis, and presence of similar illness in household contacts or school 1, 2
• Duration of symptoms: Most viral and bacterial pharyngitis resolves within 7 days; symptoms beyond 2 weeks warrant consideration of non-infectious causes 3

Objective Section

Document specific physical examination findings using the modified Centor criteria components:

• Vital signs: Document temperature (fever present or absent) 1
• Oropharyngeal examination:
  • Tonsillopharyngeal erythema (degree and distribution) 1
  • Presence or absence of tonsillar exudates (patchy versus confluent) 1
  • Palatal petechiae 1
  • Uvular appearance (swelling, erythema, deviation suggesting abscess) 1, 3
• Lymph node examination: Presence of tender, enlarged anterior cervical lymph nodes (lymphadenitis) versus generalized lymphadenopathy 1
• Respiratory examination: Presence or absence of cough 1
• Skin examination: Presence of scarlatiniform rash or viral exanthem 1, 2
• Nasal examination: Excoriated nares (especially in infants) 1
• Red flag findings requiring immediate evaluation: Unilateral tonsillar swelling, uvular deviation, trismus, "hot potato voice," severe difficulty swallowing (peritonsillar abscess); neck stiffness or swelling, drooling (retropharyngeal abscess or epiglottitis) 3, 4

Assessment Section

Calculate and document the modified Centor/McIsaac score (assign points for clinical probability):

• Tonsillar exudates: 1 point 1
• Tender anterior cervical adenopathy: 1 point 1
• Absence of cough: 1 point 1
• Fever by history: 1 point 1
• Age 3-14 years: 1 point; Age 15-44 years: 0 points; Age ≥45 years: -1 point 1

Interpret the score and document testing decision:

• Score ≤0: 1-2.5% probability of Group A streptococcal infection; testing not indicated 1, 2
• Score 1: 5-10% probability; testing generally not indicated 1
• Score 2: 11-17% probability; consider testing based on clinical judgment 1
• Score 3: 28-35% probability; testing recommended 1, 2
• Score ≥4: 51-53% probability; testing strongly recommended 1, 2

Document diagnostic test results:

• Rapid antigen detection test (RADT) result if performed 1, 2
• Note that positive RADT is diagnostic for Group A streptococcal pharyngitis 1
• Document plan for backup throat culture if RADT is negative in children and adolescents (not routinely necessary in adults) 1
• Testing should not be performed if clinical features strongly suggest viral etiology (conjunctivitis, cough, rhinorrhea, hoarseness, oral ulcers) 1, 2

Document the primary diagnosis:

• Acute pharyngitis, viral etiology (if clinical features suggest viral) 1, 2
• Acute pharyngitis, Group A streptococcal infection confirmed (if positive test) 1
• Acute pharyngitis, etiology undetermined, awaiting culture (if negative RADT with backup culture sent) 1

Plan Section

For confirmed Group A streptococcal pharyngitis:

• Antibiotic therapy: Penicillin V 250 mg orally twice or three times daily for 10 days (first-line) 1, 3, 4
• Alternative antibiotics for penicillin allergy: First-generation cephalosporin, clindamycin, clarithromycin, or azithromycin 1, 3
• Document that 10-day treatment duration is recommended; insufficient evidence supports shorter courses 1

For viral pharyngitis or low probability scores (no antibiotics indicated):

• Symptomatic treatment: Ibuprofen or acetaminophen for pain relief and fever control 1, 2, 3, 4
• Aspirin should NOT be used in children 1
• Document patient/parent education that most sore throats are viral, self-limiting within 7 days, and do not require antibiotics 2, 4

Additional plan elements:

• Follow-up instructions: Return if symptoms worsen, persist beyond 7 days, or if severe difficulty swallowing or breathing develops 2, 3
• Document that routine post-treatment testing is not recommended 1
• Document that testing of asymptomatic household contacts is not routinely recommended 1
• Patient education: Antibiotics are not needed to prevent complications like rheumatic fever in low-risk patients (those without previous rheumatic fever) 2, 4

Common Pitfalls to Avoid

• Do not prescribe antibiotics empirically without clinical assessment using validated scoring systems or microbiological confirmation 2, 3, 5
• Do not test children younger than 3 years unless risk factors present (e.g., older sibling with documented infection), as Group A streptococcal pharyngitis is uncommon in this age group 1
• Do not prescribe antibiotics for patients with 0-2 Centor criteria without positive testing, as this represents inappropriate management 2, 5
• Do not use corticosteroids routinely in treatment of Group A streptococcal pharyngitis in children 1
• Recognize that up to 20% of asymptomatic school children may be Group A streptococcal carriers; positive tests in patients with viral symptoms may represent carriage rather than true infection 1