Present Concerns/CC: “My throat hurts”

Reason given by the patient for seeking medical care “in quotes”

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Sports/physical activity; Developmental Hx)

Sexually inactive patient spends most of her time playing videogames on her Nintendo Switch. Currently enjoying summer vacation and spends her days in her grandparent’s apartment while her mom and dad work. During school time she is part of the dance group and wants to dance when she gets older.

This is a well-known patient to the office who came today with her mother complaining of a sore throat and difficulty swallowing. Her mother also states that her temperature has been a little high recently measuring around 100 degrees Farenheight for the past 3 days. The sore throat began around 5 days ago. It lasts all day long and is the same intensity throughout the day. It is a dull pain described as a 4/10. The pain worsens when she swallows any food or liquid but is worse with food.

None

Allergies: Cat Hair

Medication Intolerances:

None

Chronic Illnesses/Major traumas:

None

Hospitalizations/Surgeries: Pediatric SOAP Note Week 9 Assignment

None

Immunizations: All vaccines up to date with the exception of the most recent influenza vaccine.

Mother: 28 years old, no current health problems

Father: 29 years old, no current health problems

No siblings

Currently in summer vacation, will start 2nd grade soon. Does not work. Lives with her mom and dad in a house in Miami, FL. Single, does not use drugs, or drink alcohol. Does not use electronic cigarettes. Feels safe at home and in school.

Positive for fever, and sore throat. Denies chills, nausea, or vomiting.

Denies chest pain, pressure, palpitations.

Denies lesions, itching, or redness.

Denies shortness of breath, denies cough, and denies difficulty breathing.

Denies blurriness, denies double vision. Denies eye pain.

Denies nausea or abdominal pain. Denies diarrhea. Denies vomiting.

Denies hearing loss, pain, or drainage.

Denies increase frequency or urgency. Denies pain when voiding.

Positive for throat pain. Positive for difficulty swallowing Denies congestion, denies discharge, denies mouth pain.

Denies pain, denies limited range of movement.

Deferred

Denies headaches. Denies numbing or loss of sensation, denies dizziness, denies syncope, paralysis, or ataxia.

Denies anemia, bleeding or bruising, denies enlarged nodes. Denies change in temperature sensitivity.

Denies anxiety, or depression. Denies mood swings, denies insomnia.

Around 50th percentile

Around 50th percentile

BMI: 14.6

Growth chart at bottom of SOAP Note

Patient looks well groomed, and in no obvious distress. She came with her mother today and their interaction seems normal, there are no signs of abuse or fear.

Skin around the nose, eyes, and mouth is normal for age. No cyanosis, clubbing or bruises.

Head is normocephalic, atraumatic. Eyes: PERRLA, no conjunctival or scleral infection. Ears: bilateral TM’s pearly grey with positive light reflex. Neck: supple, full ROM. No adenopathy. Mouth/Throat: Throat is visibly red, and inflammatory. Swollen tonsils with no exudate. No presence of blood detected. Oral mucosa pink and moist, gag reflex present.

S1, S2 heard, normal rate, normal rhythm, 2 sec capillary refills, no murmurs, no gallops, no palpation, no edema.

Lungs clear to auscultation bilaterally anteriorly and posteriorly, normal respiratory effort. No rales, no Ronchi, no wheezing.

Soft to palpation. All 4 quadrants palpated, no masses. Bowel sounds present in all four quadrants. No ascites, no splenomegaly, no hepatomegaly. No rebound, no guarding. No visible signs of dehydration.

Deferred

External genitalia assessment deferred.

Normal gait and ROM. No rigidity, no deformities. No atrophy.

Normal tone, no local findings.

No depression or anxiety, no insomnia.

Rapid Antigen Strep Throat Swab – POSITIVE

Throat Culture- PENDING

Tanner Stage 1. The patient has not reached menarche. (Emmanuel & Bokor, 2019).

HEADSS Assessment (Katzenllenbogen, n.d.)

H- Lives with her mother and father in a house in Miami, FL. Have lived in this house for the past 6 years. Patient feels safe at home.

E- Currently in summer vacation. Will begin 2nd grade in the Fall.

A- Patient spends most of her days playing on her Nintendo Switch. She spends most her time at her grandparent’s house while her parents work

D- Patients states that she has never been in contact with or ever experienced being around anyone with drugs of any kind.

S- Patient is sexually inactive.

S- Patient states that she has never felt suicidal thoughts or tendencies.

· Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials)

· Document Evidence based Rationale for ROS and each differential with pertinent positives and negatives

· Primary diagnosis

· Is #1 on list of differentials

· Evidence for primary diagnosis should be supported in the Subjective and Objective exams.

2) Common Cold (B34.9) The patient has common symptoms associated with the common cold. These symptoms include sore throat, and a fever that is rising, or has lasted for more than 2 days (Common Cold, 2019)

3) Infectious Mononucleosis (B27.90) No mono spot test was conducted today, this diagnosis is not as likely, but the patient’s symptoms are also associated with infectious mononucleosis such as sore throat and fever (Mononucleosis, 2018).

· Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature.

· Include EB rationale for all aspects of your treatment plan:

· Vaccines administered this visit

· Vaccine administration forms given

· Medication-amounts and mg/kg for medications

· Laboratory tests ordered

· Diagnostic tests ordered

· Patient education including preventive care and anticipatory guidance 9 Non-medication treatments Follow-up appointment with detailed plan of f/u

The first line treatment of a strep throat infection is treating it with antibiotics. Penicillin or Amoxicillin are common treatments and should be administered for at least 10 days. Children should be given 50 mg/kg/day of Amoxicillin for streptococcal pharyngitis (Karla, Higgins, 2016). For the symptoms associated with fever and pain, NSAID’s are more effective than acetaminophen and the patient should be given a child dose of a medication such as Ibuprofen (Karla, Higgins, & Perez, 2016). Children’s Ibuprofen (100mg/5ml) is sold over the counter and should be taken every 6 hours as needed. For her sore throat, throat candies and lozenges every 2 hours can help soothe it. She should also eat and drink cold foods such as ice cream to help alleviate the pain. The patient should, above all, rest daily and drink plenty of fluids (Strep Throat, 2018) Infections usually subside after the 10-day treatment with antibiotics. If fever persists or begins to rise, the patient should be brought back to the clinic. Otherwise, we will follow up with the patient in 2 weeks to check the status of her condition and re-evaluate if necessary.

References

Common cold. (2019, April 20). Retrieved June 26, 2020, from https://www.mayoclinic.org/diseases-conditions/common-cold/symptoms-causes/syc-20351605

Emmanuel, M., & Bokor, B. R. (2019, May 13). Tanner Stages. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK470280/

Katzenellenbogen, R. (n.d.). HEADSS: The “Review of Systems” for Adolescents. Retrieved May 3, 2020, from https://journalofethics.ama-assn.org/article/headss-review-systems-adolescents/2005-03

Karla, M. G., Higgins, K. E., & Perez, E. D. (2016). Common Questions About Streptococcal Pharyngitis. American Family Physician, 94(1), 24-31.

Mononucleosis. (2018, September 08). Retrieved June 26, 2020, from https://www.mayoclinic.org/diseases-conditions/mononucleosis/symptoms-causes/syc-20350328

Strep throat. (2018, September 28). Retrieved June 26, 2020, from https://www.mayoclinic.org/diseases-conditions/strep-throat/diagnosis-treatment/drc-20350344