SOAP Note
S – Subjective
Chief Complaint (CC):
“Really bad sore throat” × 2 days, described as “ice pick” pain, 11/10.
Amanda Wheaton is a 23-year-old female law student who resides in a campus dormitory. She
presents with a 2-day history of severe sore throat, fever, and headache. She describes the throat
pain as sharp, “like an ice pick,” with severity rated up to 11/10, worsened by swallowing liquids
and solids. She reports associated fever, chills, mild dull headaches, tender swollen neck glands,
and mild hoarseness. She has difficulty swallowing but can tolerate small amounts of fluids. Her
symptoms began suddenly and have progressively worsened. Acetaminophen and ice chips
provide temporary relief. She denies cough, nasal congestion, shortness of breath, chest pain,
rash, abdominal pain, nausea, vomiting, or diarrhea. She reports a roommate with a recent sore
throat of unknown cause. She has a past history of infectious mononucleosis at age 15. She has
not received the influenza vaccine this year but is up to date with COVID immunizations. She
reports social alcohol use (2–3 drinks per week) and occasional oral sexual activity. No recent
travel. No prior recurrent strep infections or tonsillectomy. No known drug allergies.
Past Medical History: Infectious mononucleosis at age 15.
Medications: Oral contraceptive pills, OTC acetaminophen.
Allergies: NKDA.
Family History: Mother with hypertension. Father’s history unknown.
Social History: Lives in dormitory with roommate, occasional alcohol (2–3 drinks/week),
occasionally performs oral sex, non-smoker, student with academic stress.
O – Objective
Vital Signs: T 38.6 °C (101.5 °F) oral, HR 94 bpm regular, BP 126/80, RR 14, SpO₂ 98% RA,
BMI 18.8.
General: Alert, oriented ×4, cooperative, mildly ill-appearing but non-toxic.
HEENT:
• Eyes: Conjunctiva clear, sclera anicteric, PERRLA, fundi with sharp discs, red reflex
intact.
, • Ears: External ears and canals normal; Tympanic membranes is pearly-gray, intact, no
erythema or exudates.
• Nose: No rhinorrhea; no sinus tenderness.
• Oropharynx: Posterior pharyngeal erythema, tonsils moderately enlarged with bilateral
exudates (R>L), uvula midline, halitosis present. No ulcers, no trismus.
Neck/Lymphatic: Trachea midline. Tender bilateral anterior cervical lymphadenopathy (≈1.5 cm,
mobile, rubbery). No posterior nodes, no hepatosplenomegaly.
Skin: Warm, dry, intact; no rash.
Cardiovascular: RRR, no murmurs, rubs, or gallops; normal pulses.
Respiratory: CTAB, no adventitious sounds.
Abdomen: Soft, non-tender, no organomegaly.
Musculoskeletal: Full ROM, no joint swelling/tenderness.
Neuro: CN grossly intact, coordination/gait normal.
Psychiatric: Pleasant, cooperative, good eye contact; affect appropriate; thought process logical,
goal-directed.
A – Assessment
Primary Diagnosis:
Pharyngitis, Group A Streptococcal (GAS)
• Supported by: acute onset severe sore throat described as “ ice pick pain”, fever >101 °F,
tonsillar exudates, tender anterior cervical nodes, sick contant and absence of cough (Centor
/McIsaac score high). Rapid antigen test ( Negative) is highly specific for GAS but less sensitive.
Meaning a positive test confirms strep, but a negative test doesn't rule out infection.
Differential Diagnoses:
• Viral pharyngitis (considered; less likely due to severity, exudates, tender anterior nodes).
• Infectious mononucleosis (history of prior mono, no posterior nodes or
hepatosplenomegaly; less likely here). However exudate and pain intensity of 11/10, cough
absence suggest - bacterial infection.
• Peritonsillar abscess (ruled out: no uvular deviation, trismus, or muffled “hot potato”
voice).
S – Subjective
Chief Complaint (CC):
“Really bad sore throat” × 2 days, described as “ice pick” pain, 11/10.
Amanda Wheaton is a 23-year-old female law student who resides in a campus dormitory. She
presents with a 2-day history of severe sore throat, fever, and headache. She describes the throat
pain as sharp, “like an ice pick,” with severity rated up to 11/10, worsened by swallowing liquids
and solids. She reports associated fever, chills, mild dull headaches, tender swollen neck glands,
and mild hoarseness. She has difficulty swallowing but can tolerate small amounts of fluids. Her
symptoms began suddenly and have progressively worsened. Acetaminophen and ice chips
provide temporary relief. She denies cough, nasal congestion, shortness of breath, chest pain,
rash, abdominal pain, nausea, vomiting, or diarrhea. She reports a roommate with a recent sore
throat of unknown cause. She has a past history of infectious mononucleosis at age 15. She has
not received the influenza vaccine this year but is up to date with COVID immunizations. She
reports social alcohol use (2–3 drinks per week) and occasional oral sexual activity. No recent
travel. No prior recurrent strep infections or tonsillectomy. No known drug allergies.
Past Medical History: Infectious mononucleosis at age 15.
Medications: Oral contraceptive pills, OTC acetaminophen.
Allergies: NKDA.
Family History: Mother with hypertension. Father’s history unknown.
Social History: Lives in dormitory with roommate, occasional alcohol (2–3 drinks/week),
occasionally performs oral sex, non-smoker, student with academic stress.
O – Objective
Vital Signs: T 38.6 °C (101.5 °F) oral, HR 94 bpm regular, BP 126/80, RR 14, SpO₂ 98% RA,
BMI 18.8.
General: Alert, oriented ×4, cooperative, mildly ill-appearing but non-toxic.
HEENT:
• Eyes: Conjunctiva clear, sclera anicteric, PERRLA, fundi with sharp discs, red reflex
intact.
, • Ears: External ears and canals normal; Tympanic membranes is pearly-gray, intact, no
erythema or exudates.
• Nose: No rhinorrhea; no sinus tenderness.
• Oropharynx: Posterior pharyngeal erythema, tonsils moderately enlarged with bilateral
exudates (R>L), uvula midline, halitosis present. No ulcers, no trismus.
Neck/Lymphatic: Trachea midline. Tender bilateral anterior cervical lymphadenopathy (≈1.5 cm,
mobile, rubbery). No posterior nodes, no hepatosplenomegaly.
Skin: Warm, dry, intact; no rash.
Cardiovascular: RRR, no murmurs, rubs, or gallops; normal pulses.
Respiratory: CTAB, no adventitious sounds.
Abdomen: Soft, non-tender, no organomegaly.
Musculoskeletal: Full ROM, no joint swelling/tenderness.
Neuro: CN grossly intact, coordination/gait normal.
Psychiatric: Pleasant, cooperative, good eye contact; affect appropriate; thought process logical,
goal-directed.
A – Assessment
Primary Diagnosis:
Pharyngitis, Group A Streptococcal (GAS)
• Supported by: acute onset severe sore throat described as “ ice pick pain”, fever >101 °F,
tonsillar exudates, tender anterior cervical nodes, sick contant and absence of cough (Centor
/McIsaac score high). Rapid antigen test ( Negative) is highly specific for GAS but less sensitive.
Meaning a positive test confirms strep, but a negative test doesn't rule out infection.
Differential Diagnoses:
• Viral pharyngitis (considered; less likely due to severity, exudates, tender anterior nodes).
• Infectious mononucleosis (history of prior mono, no posterior nodes or
hepatosplenomegaly; less likely here). However exudate and pain intensity of 11/10, cough
absence suggest - bacterial infection.
• Peritonsillar abscess (ruled out: no uvular deviation, trismus, or muffled “hot potato”
voice).
