H&P #2

IDENTIFYING DATA:

  • Date & Time: B.K.
  • Full Name: July 7, 2023
  • DOB: 4/11/2016
  • Location: Dr. Hurwitz Pediatric Outpatient Office
  • Source of information: patient / mother
  • Reliability: reliable

CHIEF COMPLAINT: “my throat hurts” x 2 days

HISTORY OF PRESENT ILLNESS:

B. K. is a 6 year old female BIB mother with no significant PMHx c/o sore throat x 2 days. Patient states the pain worsens when she swallows. As per mother patient has been eating a bit less due to pain but is able to tolerate foods and liquids. Mother reports fever yesterday, Tmax 101.2 F (oral) which was relieved with OTC motrin, last dose 4 hours ago. Patient has been gargling with salt water. Patient’s cousin recently whom she recently spent time with had similar symptoms and was treated for strep. Denies cough, nasal congestion, N/V/D, rash, headache, body aches, drooling, neck pain, voice changes, recent travel.

MEDICAL HISTORY:

Medications:

  • OTC Motrin PRN

Medical History:

  • No past medical history

Surgical History:

  • No past surgical history

Immunization Hx:

  • Vaccinations UTD

Allergies:

  • No known drug, food or environmental allergies

Family History:

  • Mother: age 26, alive and well, no past medical history
  • Father: age 28, alive and well, no past medical history
  • 1 sister: age 2, alive and well, no past medical history
  • Maternal grandparents: alive and well, no known medical history
  • Paternal grandparents: alive and well, no known medical history
  • Denies known family history of cancer, DM or MI.

 Social History:

  • Lives with mother, father and sister in home in Kew Garden Hills
  • No smokers in home, no pets
  • Safety: patient uses safety belt while in car; home equipped with smoke and carbon monoxide detectors
  • Attends summer day camp
  • Schooling: Patient will be attending 1st grade in the fall
  • Social: Patient attends day camp; interacts daily with sister and cousins; has friends from school who she sometimes visits their homes
  • Home situation: mother denies stressors at home for patient
  • Travel: denies recent travel
  • Exercise: daily exercise, takes swimming lessons
  • Sleep: average 8 hours of sleep per night
  • Diet: home cooked meals cooked by mother or grandmother; follows kosher diet; patient sometimes eats outside food such as pizza

Parent Questionnaire Age 6-7:

  • Do you have concerns about your child’s:
    • Overall progress in school – NO
    • Ability to sit still, listen or participate – NO
    • Willingness to follow rules at school – NO
    • Ability to get along with peers and teachers – NO
    • School attendance – NO
    • Overall health and development – NO
    • Eating habits (excessive or improper snacks) – NO
    • Sleeping habits (nightmares, sleep walking) – NO
    • Energy levels or stamina – NO
    • Frequent colds, ear infections, allergies – NO
    • Frequent bouts of abdominal pain, vomiting, diarrhea – NO
    • Irritability, temper outbursts, excessive anger – NO
  • Does he/she have adult supervision before and after school? – YES
  • Does he/she use a helmet for skating or biking? – YES
  • Does he/she use a seat belt and ride in the backseat – YES
  • Does he/she live in a gun free home? – YES

 Birth History:

  • Birth weight: 7 lbs 2 oz
  • Birth Hospital: Northshore LIJ Hospital
  • NSVD, no complications during pregnancy or delivery

REVIEW OF SYSTEMS

  • General: Admits to fever. Denies weight loss, changes in appetite, weakness, fatigue, chills.
  • Skin, hair, nails: Denies rash, discolorations, abnormal pigmentations.
  • Head: Denies headaches, dizziness or head trauma.
  • Eyes: Denies eye pain or pruritus.
  • Ears: Denies pain, discharge, tinnitus.
  • Nose/sinuses: Denies discharge, congestion, and epistaxis.
  • Mouth/throat: Admits to sore throat. Denies bleeding gums, sore throat, voice changes. Last dental visit 2 months ago.
  • Neck: Denies swelling or decreased range of motion.
  • Pulmonary system: Denies shortness of breath, cough, wheezing.
  • Cardiovascular system: Denies chest pain.
  • Gastrointestinal system: Has regular bowel movements daily. Denies constipation, diarrhea, bloody stools, nausea, vomiting.
  • Genitourinary system: Denies dysuria, urinary frequency, oliguria.
  • Nervous: Denies loss of strength.
  • Musculoskeletal system: Denies muscle/joint pain or redness.
  • Hematological system: Denies easy bruising or bleeding.
  • Endocrine system: Denies heat or cold intolerance or excessive sweating.

PHYSCIAL:

General: Appears stated age. Good development and well groomed. Appears well nourished and in no acute distress.

Vitals:

  • Pulse: 92 beats/min, regular
  • Respiratory Rate: 20 breaths/min, unlabored
  • Temp: 99.1 F (oral)
  • Wt: 49 lbs (65th percentile)
  • Ht: 45.5” (52nd percentile)

Skin: Skin warm and nonicteric. No rashes, masses, scarring or bruising noted.

Head: Head normocephalic, atraumatic.

Hair: Average quantity. No lice or seborrhea noted.

Nails: No spooning or clubbing of nails.

Head: Head normocephalic, atraumatic.

Eyes: Symmetrical OU. Sclera white. Conjunctiva pink. PERRLA OU. EOMI with no nystagmus.

Ears: Symmetrical, no swelling or lesions to external ear. No discharge or foreign bodies present AU. TM pearly grey with light reflex in good position AU.

Nose: Nares patent bilaterally. No discharge or foreign bodies noted.

Mouth/Pharynx: +Pharyngeal erythema +Tonsillar erythema & enlargement, grade 3, with no exudates present. Good dentition, no obvious dental caries noted. No gingival hyperplasia or erythema present. Tongue without lesions. Uvula midline.

Neck: Trachea midline. Neck supple; non-tender to palpation. No cervical adenopathy noted. FROM.

Thyroid: Non-tender; no palpable masses or nodules; no thyromegaly.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4.

Lungs: Clear to auscultation bilaterally, no adventitious sounds noted.

Abdomen: Abdomen flat and symmetric, no masses, ecchymosis or striae noted. Bowel sounds normoactive in all four quadrants. Non-tender to palpation, no guarding or rebound noted. Tympanic throughout. No splenomegaly.

Musculoskeletal: No soft tissue swelling. FROM in upper and lower extremities.

DIFFERENTIAL DIAGNOSIS:

  • Strep pharyngitis
  • Tonsilitis
  • Viral syndrome
  • Mononucleosis
  • Peritonsillar abscess
  • Retropharyngeal abscess
  • Herpangia
  • Kawasaki’s
  • Diphtheria
  • Epiglottitis

Workup:

  • Rapid strep
  • Overnight Strep culture

ASSESSMENT:

B.K is a 6 year old female BIB mother c/o sore throat x 2 days. Patient is hemodynamically stable and does not appear in any acute distress. On exam there is pharyngeal erythema and tonsillar enlargement & erythema. Rapid strep completed in office was positive.

PLAN:

#Strep Pharyngitis – Centor criteria 3 out of 4

  • Rapid strep +
  • Amoxicillin 400 mg 100 cc 1tsp BID for 10 days
  • OTC Tylenol or motrin PRN for fever and pain

Patient Education:

  • Strep is a contagious bacterial infection in the throat that is common in school aged children.
  • Take antibiotics as directed for full course – not taking antibiotics can lead to complications such as rheumatic fever
  • Patient should remain home from day camp until she has been taking antibiotics for 24 hours and is fever free for 24 hours
  • Practice good hand hygiene
  • Isolate from sibling if possible
  • Drink plenty of fluids to stay hydrated
  • Use OTC motrin or Tylenol for pain
  • Don’t share food, dishes or utensils

Return precautions: please return to office or go to ER if:

  • Difficulty breathing/SOB
  • Unable to swallow
  • Unable to open mouth or speak
  • High persistent fever
  • Pain worsens