| Name: Jack Anderson | Date: | |
| Sex: Male | Age/DOB/Place of Birth: 9 years. 10/12/2010. Austin, Texas. | |
| SUBJECTIVE
The majority of the information and complaints were obtained from the patient. More in-depth information and medical history were provided by patient’s father, Mr. Anderson, who initiated the visit to the hospital. |
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| Historian: Jack is white Caucasian. He is the only child in the family and lives with his mother, father, and grandparents.
Present Concerns/CC: The patient complaints on sore throat, fatigue, and tiredness. The reasons that provoked patient for seeking medical care include “fever,” “disorientation,” “tiredness,” “pain in throat,” and “cough.” The patient experiences mentioned symptoms for four days. The father added that Jack has temperature of 102F. |
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| Child Profile: attends school, plays with friends, and helps father with daily chores. Recently, the schoolteacher noticed that Jack’s activity during the class has decreased. Developmental Hx: meets the required norms of developmental milestones of walking and talking. Prior to the occurrence of symptoms participated in soccer team. | ||
| HPI: The patient says that he experiences an acute pain in throat during such activities as food consumptions, drinking, swallowing, and chewing. Father has also added that the temperature is higher during nights and ranges between 102 and 103F. As a result, the patient lacks appropriate amount of sleep and experiences tiredness and disorientation.
Location: throat. Quality: according to Jack’s description, his throat hurts and tickle. Severity: 5 according to Faces Scale. Timing: the symptoms last for 4 days. Setting: father states that Jack was visiting his cousin four days ago. He came back home complaining on the mild pain and tickling in throat. Aggravating factors: The pain in throat becomes worse when Jack tries to swallow. Apart from that, he indicated that he experiences strong tickling in throat at night. Additional signs and symptoms: fatigue and tiredness as a result of bad sleep. Decreased attention and activity at school. Slightly decreased appetite due to the painful notion during the process of swallowing. Fever of 103F (at night). |
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| Medications: Father stated that Jack took Tylenol to decrease fever. Except this medication, Jack does not consume any prescribed drugs. | ||
| PMH:
Allergies: absence of food and drug allergies. Medication Intolerances: unknown Chronic Illnesses/Major traumas: no medical history of chronic illnesses and major physical traumas. Hospitalizations: no hospitalizations. Surgeries: no surgeries. Immunizations: age appropriate immunization including flu-vaccine received in September 2018. |
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| Family History: The patient is the only child in the family. He lives with mother, father, and maternal grandparents. Father is 40 and lacks current health problems. He has a medical history of pneumonia. The mother is 38, and according to father, she has no problems with health. Yet, she had certain problems during pregnancy (father did not provide accurate information). Maternal grandfather is 65 and has a history of cardiovascular diseases, asthma, and incident of myocardial infarction. The maternal grandmother is 66 and has the history of cardiovascular problems and cervical cancer. The father is not aware about the health problems of cousin, whom Jack visited before the appearance of symptoms. | ||
| Social History: Jack is in fifth grade. He likes sports and plays in the local soccer team. Jack also likes hiking and spending time with his friends. The father states that he used to smoke but quit two years ago. The mother and grandparents does not smoke and rarely consume alcohol. The family follows healthy way of life based on healthy nutrition and physical activity. | ||
| ROS | ||
| General
Father reports fever, tiredness, and decreased activity during classes at school. No weight loss. |
Cardiovascular
No history of chest pains. Absence of activity intolerance. The patient was very active prior to the occurrence of symptoms. |
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| Skin
No problems with skin lesion and pigmentation. |
Respiratory
The patient complaints on mild cough. He does not have medical history of respiratory infections or problems with breathing. |
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| Eyes
Jack does not have problems with vision. He lacks dry eyes and problems with focusing. The last vision exam, conducted in 2017, showed 20/20. |
Gastrointestinal
The patient complaints on problems with swallowing. There are no vomiting, abdominal pain bloating, food intolerance, problems with diarrhea or constipations. According to father, the appetite has slightly decreased for the last two days. |
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| Ears
No complaints on hearing. No history of ear infections. He does not experience ear pressure. |
Genitourinary
He does not have problems with incontinence and nocturia. Jack does not have medical history of kidney stones. |
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| Nose/Mouth/Throat
He does not have runny nose, dental problems, and oral lesion. Complaints on the acute pain and tickling in throat |
Musculoskeletal
Jack does not experience back, neck, and joint pain. Denies cramps and stiffness. He does not have problems with walking and outdoor activities. |
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| Breast
n/a |
Neurological
Lack of neurological problems, seizures, and involuntary movement of limbs. Father reports decreased activity and tiredness. |
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| Heme/Lymph/Endo
No bleedings and bruises. No lymph nodes enlargement. He does not have history of blood transfusion. Jack lacks changes in weigh, skin, and hair. He does not report problems with hormones. Absence of history of hormone therapy. |
Psychiatric
He does not report depression, anxiety, mood swings, and anger. |
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| OBJECTIVE
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| Weight: 87lbs (60th percentile) | Temp: 99.2 | BP: 108/69 |
| Height: 4’8 (90th percentile) | Pulse: 75 | Resp: O2-100%
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| Appearance and parent?child interaction
The patient looks well-nourished and without the symptoms of distress. Appearance is healthy. Ambulation is normal. He expresses the signs of tiredness. No delays in physical development. Normal parent-child interaction. |
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| Skin
No skin lesion. The color of skin is healthy. |
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| HEENT
No bruises and scaling on a head. The sclera is white and extra ocular movement is normal. The appearance of ears is normal. No visible redness or lesion. The otoscope exam showed clear membranes. Nose has normal appearance without inflammation. There are no presence of mucus. The throat is red and swollen. The signs of inflammation of pharynx are present. |
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| Cardiovascular
Normal heart rate and rhythm without murmurs. PP: 2+ bilaterally. No bruits in arteries. |
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| Respiratory
Lungs are clear without noises. Even and unlabored respiration. No signs of shortness of breath. |
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| Gastrointestinal
Palpation of abdomen showed no masses. The abdomen is soft. BS is present. |
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| Breast
N/A |
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| Genitourinary
Absence of bladder distention. |
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| Musculoskeletal
The both grips are equal and normal. Normal joint stability. No signs of muscle weakness. Stands and walks normally. |
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| Neurological
Normal concentration and attention. Verbal communication is normal. Response to touch and light is normal. |
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| Psychiatric
Normal cognitive skills. No signs of depression. Normal and cooperative mood. |
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| In-house Lab Tests
Rapid Strep Screen Test. The complaints of the patients and the condition of throat indicate the presence of infection. Results: positive. |
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| Assessment Tools
ACEs Family Health History and Health Appraisal Questionnaire. Showed absence of malnutrition, maltreatment, and exposure to domestic violence. Child Stress Disorders Checklist (CSDC). Showed lack of depression and anxiety. Ages and Stages Questionnaire. Showed normal language development, motor skills, and problem solving skills. Hunger Vital Sign. Showed absence of food insecurity. These tools were chosen to conduct sufficient socio-emotional assessment of the patient. |
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| Diagnosis | ||
| Primary diagnosis
Streptococcal pharyngitis/ Streptococcal sore throat (ICD-10 Code J020). Subjective exam: fever, sore throat, red throat. Objective: Positive strep test. Differential diagnoses Tonsillitis (ICD-10 Code J03.90). Subjective exam: sore throat, fever, problems with swallowing. Objective exam: positive strep test refutes diagnosis. Mononucleosis (ICD-10 Code B27.9). Subjective: tiredness, fever. Objective exam: positive strep test refutes diagnosis. |
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| Treatment Plan | ||
| The treatment of Streptococcal pharyngitis/ Streptococcal sore throat would be based on oral administration Cefadroxil (Martin, 2015). The dosage is 20mg/kg. Duration of treatment is 10 days. Apart from that, the patient should continue to take Tylenol to control temperature. Even though treatment of Streptococcal pharyngitis with amoxicillin is supported by American Academy of Pediatrics, the Food and Drug Administration does not approve administering this drug for children aged under 12 (Oliver et al, 2018). In addition, the studies show that Cefadroxil effectively copes with streptococcal infection located in throat (Weber, 2014). The visit did not include vaccination since the patients has all age appropriate vaccines. The laboratory test on streptococcus was ordered since this infection is highly contagious and could be source of sore throat (Gidengil, Kruskal, & Lee, 2013). Thus, there was no need in additional diagnostic and laboratory tests since clinical presentation of patient’s symptoms was obvious and Rapid Strep Test showed positive result.
Education The patients should be informed that streptococcus is highly contagious infections; thus, the contact with people should be limited. The preventive measure should include washing hands as well as not sharing food and utensils with other children. Moreover, the patient should be informed that administration of the prescribed drug could violate the work of gastrointestinal tract, thus resulting in diarrhea. Non-medication treatment should include sufficient consumption of fluids. After the full course of treatment, the patient should refer to physician. In case of aggravation of symptoms, parents should immediately contact primary care physician. |
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Self-Assessment
I believe that visit was successful since the patient was diagnosed based on the symptoms and lab test. Moreover, all complaints were analyzed and taken into consideration during the process of establishment of diagnosis. Perhaps, it would be more beneficial for the establishment of the diagnosis to pay more attention to the complaints of the patient and evaluation of HPI.