Date:
Patient:
MRN:
Clincian: (Pediatrician, Primary Care Physician)
Reason for Visit:
Evaluation for sore throat and possible strep throat
Review of symptoms and potential exposures
Rapid strep test or throat culture
Discussion of treatment plan and potential complications
History of Present Illness:
Briefly describe the patient’s current symptoms:
Sudden onset of sore throat
Pain with swallowing (odynophagia)
Fever (>100.4°F)
Headache
Malaise (general feeling of discomfort)
Neck pain or swollen lymph nodes
Cough (less common)
Past Medical History:
Past history of strep throat (increased risk of recurrence)
Underlying medical conditions (immunosuppression)
Social History:
Recent exposure to someone with strep throat (increased risk)
Physical Exam:
Vital Signs: May be elevated temperature with fever.
ENT exam:
Erythematous (red) and swollen pharynx (throat)
Tonsillar enlargement may be present with or without exudates (pus)
Palpable and tender anterior cervical lymph nodes (swollen glands in the neck)
Labs:
Rapid strep test (preferred initial test): Provides a quick result (within minutes) to confirm or rule out strep A infection.
Throat culture (if rapid strep test is negative and clinical suspicion is high): Sent to a laboratory for definitive diagnosis of strep A bacteria.
Assessment:
Summarize the diagnosis:
Confirmed strep throat based on a positive rapid strep test or throat culture.
Possible strep throat if rapid strep test is negative but clinical suspicion remains high (throat culture pending).
Viral pharyngitis more likely if rapid strep test is negative and clinical presentation is not suggestive of strep A infection.
Plan:
Outline the treatment plan based on the diagnosis:
Confirmed strep throat:
Antibiotics (penicillin or amoxicillin) are prescribed for a full course to eradicate the bacteria and prevent complications like rheumatic fever.
Consider mentioning symptomatic relief measures (lozenges, gargling with warm salt water) for throat discomfort.
Possible strep throat (pending culture):
Antibiotics may be initiated while awaiting culture results, especially if symptoms are severe.
Treatment plan will be adjusted based on the final culture result.
Viral pharyngitis:
Supportive care for symptom relief (over-the-counter pain relievers, rest, fluids).
Antibiotics are not effective for viral infections.
Prognosis:
Briefly discuss the prognosis. Strep throat typically resolves within a week with antibiotic treatment.
Emphasize the importance of completing the full course of antibiotics, even if symptoms improve, to prevent complications.
Education:
Document any education provided to the patient regarding:
The difference between strep throat and viral pharyngitis
The importance of completing the full course of antibiotics, even if symptoms improve
Preventing the spread of strep throat (frequent hand washing, avoiding close contact with sick individuals)
Warning signs and symptoms of complications (worsening symptoms, difficulty breathing)
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about medication side effects, potential complications, or home care measures.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a pediatrician or primary care physician for diagnosis, treatment recommendations, and prognosis.