Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Herpangina
A communicable viral disease characterized by the abrupt onset of fever and vesicular eruptions of the anterior tonsillar pillars.
I. Etiology: Coxsackievirus A, Echovirus
II. Incidence
A. Highly infectious disease generally occurring among infants and children in epidemic form
B. Seen mainly in summer and early fall.
C. Other types of coxsackieviruses may be present in the community at the same time.
III. Incubation period: 3 to 5 days
IV. Communicability
A. Usually fecal–oral or oral–oral.
B. Less commonly airborne transmission.
C. Virus can be isolated from feces several weeks after recovery.
V. Subjective data
A. Abrupt onset of fever up to 105F (40.5C)
B. Dysphagia occurring within 24 to 36 hours
C. Sore throat after temperature elevation
D. Anorexia
E. Occasionally headache, vomiting, and abdominal pain
F. Convulsions may occur with abrupt onset of fever.
VI. Objective data
A. Elevated temperature
B. Hyperemia of anterior tonsillar pillars
C. Grayish-white vesicles on an erythematous base on anterior tonsillar pillars, also, but less frequently, on soft palate, tonsils, and uvula
D. Vesicles ulcerate rapidly, leaving shallow ulcers.
E. There is no involvement of gingival or buccal mucosa.
F. Mild cervical adenitis
VII. Assessment
A. Diagnosis: Classic case easily diagnosed by the clinical picture
B. Differential diagnosis
1. Hand-foot-and-mouth disease: Clinical picture similar, but small, grayish papulovesicular lesions on palms of hands and soles of feet
2. Acute gingivostomatitis (herpes simplex): Gingival and buccal mucosa involved
VIII. Plan
A. Treatment is symptomatic.
B. Warm saline mouth rinses
C. For elevated temperature or discomfort
1. Acetaminophen 10 to 15 mg/kg every 4 hours or
2. Ibuprofen 5 to 10 mg/kg every 6 to 8 hours
D. Chloraseptic gargle for children over 6 years of age only; may be used every 2 hours
E. Tepid baths for elevated temperature
F. Force fluids (cold, bland liquids); also try Popsicles, Jell-O, sherbet. Avoid carbonated beverages or acidic juices.
G. Soft, bland diet; try yogurt, puddings.
IX. Education
A. Call back if child will not take fluids or is vomiting.
B. Fever will last 1 to 4 days; systemic symptoms improve in 4 to 5 days; recovery generally is complete within 1 week.
C. Tepid water for baths; air dry or rub briskly with towel.
D. Do not overdress; keep child cool.
E. Be alert for dehydration (see Appendix H, p. 534)
F. Transmitted by direct contact with nose and throat secretions, stools, and blood of infected child
G. Keep child isolated until temperature is normal for 24 hours.
H. Highly contagious, at least during acute phase
I. There is no prophylaxis.
J. Carbonated drinks; citrus juices; hot, spicy foods and the like should be avoided, because they may increase discomfort.
K. Do not be concerned about dietary intake during acute stage, but do force fluids.
L. Prognosis is excellent; herpangina is self-limited.
M. Immunity to infecting strain is generally conferred after one attack.
X. Follow-up
A. Maintain daily telephone contact during acute phase.
B. Generally, no follow-up visit is necessary.
XI. Complications
A. Febrile convulsions
B. Dehydration
XII. Consultation/referral
A. Signs of dehydration
B. Prolonged course if child’s condition has not improved in 5 days
C. Febrile convulsions