SUBJECTIVE DATA (S):
IDENTIFYING DATA:
Initials: J.S.
Age: 10 years
Race: Caucasian
Gender: Male
Patient is accompanied by his mother who is the informant.
CHIEF COMPLAINT (CC): Mother states that the patient complains of “sore throat and
fever for 3 days.”
HISTORY OF PRESENT ILLNESS (HPI): Patient c/o sore throat and fever for 3 days.
Patient states that his throat hurts really bad when he swallows and his throat feels raw.
Mother states that his temperature last night was 103 and he complained of a cough and ear
pressure as well as throat pain.
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location: throat
quality: patient describes a feeling of rawness
severity: 7 on FACES pain scale
timing: symptoms started 3 days ago
setting: Mother explains the patient came home from school 3 days ago
complaining of a sore throat.
alleviating and aggravating factors: pain in throat is worse when the patient
tries to eat or swallow anything. It is also worse when he wakes up first thing in
the morning and at night before bedtime.
associated signs and symptoms: cough and ear pressure that started last night.
Mother states he has had a decreased appetite and has just not acted like
himself.
PAST MEDICAL HISTORY (PMH):
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Allergies: NKDA
Current medications: No prescribed medications. Mother states she has been
giving him OTC Children’s Tylenol 12.5ml every 4 hours as needed for his fever.
Age/health status: 10 years/ No chronic health problems
Appropriate immunization status: Up to date on all vaccines; Mother states he
did receive a flu vaccine last year and will receive one this year at his primary
physician’s office this fall
Dates of illnesses during childhood: N/A
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Injuries: N/A
Hospitalizations: No hospitalizations
Surgeries: No surgeries
Health maintenance and health promotion:
- Good compliance with annual check-ups with pediatrician; has an
appointment for October 2014
- Dental visit every 6 months; brushes teeth twice a day. No cavities at last
appointment that was 3 months ago
- Mother stresses importance of hand washing to child
- Well balanced diet
- Very active; physical activity for at least 1 hour per day. Allowed to watch
1 hour of TV per day.
FAMILY HISTORY (FH): Patient is an only child. Mother is 33 years old and father is 35
years old. Mother reports no health problems for herself or the father. Maternal grandmother
is 54yo and has no known health problems. Maternal grandfather is 55yo and has HTN. Paternal
grandmother is 57yo and has a history of breast cancer with a bilateral mastectomy but is now
in remission. Paternal grandfather is 60yo and has Type II diabetes.
SOCIAL HISTORY (SH): Patient will be in the 5th grade this school year. He is very active
and plays football for his school. He was also on a summer league baseball team. Mother states
she and the father do not smoke. They do drink alcohol occasionally. Patient does not drink
caffeine. He is allowed to watch 1 hour of TV per day.
REVIEW OF SYSTEMS (ROS):
1. Constitutional symptoms- Mother reports fever, fatigue, and decreased
appetite. Denies difficulty sleeping, chills, malaise, night sweats, unexplained
weight loss or weight gain.
2. Eyes- Denies blurred vision, difficulty focusing, ocular pain, diplopia, scotoma,
peripheral visual changes, and dry eyes. No corrective lenses. Mother states date
of last eye exam was in 2013 and exam was reported normal (20/20 vision).
3. Ears, nose, mouth, and throat- Mother reports sore throat and ear pressure.
Patient states his throat hurts really bad when he swallows and his throat feels
raw. Denies headaches, hoarseness, vertigo, sinus problems, epistaxis, dental
problems, oral lesions, hearing loss or changes, nasal congestion. Date of last
dental visit was about 3 months ago.
4. Cardiovascular- Mother states patient is very active and participates in sports.
He participates in physical activity for at least an hour per day. Denies any history
of heart murmur, chest pain, palpitations, dyspnea, activity intolerance, varicose
veins, edema.
5. Respiratory- Mother reports cough that started last night. Denies history of
respiratory infections, SOB, wheezing, difficulty breathing, exposure to
secondary smoke, exposure to TB, hemoptysis.
6. Gastrointestinal- Mother reports patient has a decreased appetite. He complains
of pain when he swallows; dyspahgia. Denies reflux, pyrosis, bloating, nausea,
vomiting, diarrhea, constipation, hematemesis, abdominal or epigastric pain,
hematochezia, change in bowel habits, food intolerance, flatulence,
hemorrhoids. Mother states she tries to prepare healthy, well-balanced meals.
7. Genitourinary- Mother denies urgency, frequency, dysuria, suprapubic pain,
nocturia, incontinence, hematuria, history of stones.
8. Musculoskeletal- Mother denies back pain, joint pain, swelling, muscle pain or
cramps, neck pain or stiffness, changes in ROM. She states patient is active for at
least an hour per day. He does wear his seatbelt.
9. Integumentary- Mother denies itching, uritcaria, hives, nail deformities, hair
loss, moles, open areas, bruising, and skin changes. She states she applies
sunscreen while outside and inspects his skin regularly for any changes.
10. Neurologic- Mother denies headache, weakness, numbness, tingling, memory
difficulties, involuntary movements or tremors, syncope, stroke, seizures,
paresthesias.
11. Psychiatric- Mother denies nightmares, mood changes, anxiety, depression,
nervousness, insomnia, suicidal thoughts, exposure to violence, or excessive
anger.
12. Endocrine- Mother denies cold or heat intolerance, polydipsia, polyphagia,
polyuria, changes in skin, hair or nail texture, unexplained change in weight,
changes in facial or body hair, changes in hat or glove size, use of hormonal
therapy.
13. Hematologic/lymphatic- Mother denies unusual bleeding or bruising, lymph
node enlargement or tenderness, fatigue, history of anemia, blood transfusions.
14. Allergic/immunologic- Mother denies seasonal allergies, allergy testing,
exposure to blood or body fluids, use of steroids, or immunosuppression in self
or family.
OBJECTIVE DATA (O):
1. Constitutional- VS: Temp- 98.6, BP- 100/68, HR- 74, RR- 20, O2 sat- 100%,
Height- 4’11.5” (91st percentile), Weight- 79 lbs (59th percentile), BMI- 15.7 (24th
percentile); General Appearance: healthy-appearing, well-nourished, and welldeveloped . Level of Distress: NAD. Ambulation: ambulating normally.
2. Eyes- sclerae white. Conjunctivae pink. Pupils are PERRL, 3 mm bilaterally.
Extraocular movements intact.
3. Ear, Nose, Throat-
Ears: external appearance normal-no lesions, redness, or swelling; on otoscopic
exam tympanic membranes clear, no redness, fluid, or bulging noted. Hearing is
intact.
Nose: appearance of nose normal with no mucous, inflammation, or lesions
present. Nares patent. Septum is midline.
Mouth: pink, moist mucous membranes. No missing or decayed teeth.
Throat: Very erythematous (fire engine red in appearance). Inflamed uvula,
pharynx, and tonsils. No lesions present. No ulcers, masses, or exudate present.
4. Cardiovascular- S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs
Carotid Arteries: normal pulses bilaterally, no bruits present
Pedal Pulses: 2+ bilaterally
Extremities: no cyanosis, clubbing, or edema, less than 2 second refill noted
5. Respiratory- Even and unlabored. Clear to auscultation bilaterally with no
wheezes, rales, or rhonchi
6. Gastrointestinal- abdomen soft and nontender to palpation, nondistended. No
rigidity or guarding, no masses present, BS present in all 4 quadrants
7. Genitourinary- No bladder distention, suprapubic pain, or CVA tenderness.
8. Musculoskeletal- joint stability normal in all extremities, no tenderness to
palpation
9. Integument/lymphaticInspection: No scaling or breaks on skin, face, neck, or arms.
General palpation: no skin or subcutaneous tissue masses present, no
tenderness, skin turgor normal
Face: no rash, lesion, or discoloration present
Lower Extremities: no rash, lesion, or discoloration present
Upper Extremities: no rash, lesion, or discoloration present
10. Neurologic- Grossly oriented x3, communication ability within normal limits,
attention and concentration normal. Sensation intact to light touch, gait within
normal limits
11. Psychiatric- Judgment and insight intact, rate of thoughts normal and logical.
Pleasant, calm, and cooperative. Patient appears to be happy/content.
12. Hematologic/immunologic- Lymph nodes not palpable, no tenderness or masses
present, no bruising
DIAGNOSTIC TESTS:
RAPID STREP GROUP A, THROAT - 07/30/14
CPT code: 87880
Results- Strep: positive
ASSESSMENT (A):
Level of visit: new office outpatient visit- 99203
1. Streptococcal throat/ Infectious pharyngitis
034.0: Streptococcal sore throat
462.0: Acute pharyngitis
Sore throat x3 days, fever, describes pain as a feeling of rawness. Throat- very
erythematous (fire engine red in appearance). Inflamed uvula, pharynx, and
tonsils. Positive strep test.
Differential Diagnoses:
1. Viral pharyngitis
Sore throat x3 days, fever, fatigue, cough, pharynx is erythematous.
Refuting data: Positive strep test
2. Tonsillitis
Patient c/o sore throat and difficulty swallowing, fever. Tonsils are edematous.
Refuting data: Positive strep test
3. Mononucleosis
Patient c/o sore throat x3 days, fatigue, fever
Refuting data: Positive strep test
PLAN (P):
1. Bicillin L-A 1,200,000 units/2ml IM syringe
Inject 1.2ml by intramuscular route in office
- Indication: Group A streptococcal infection
- MOA: Interferes with cell wall mucopeptide synthesis during active
multiplication, resulting in bactericidal activity against susceptible
microorganisms
- Dose: >27kg: 1.2 million units IM x1
- Brand name/generic: Bicillin L-A (penicillin G benzathine)
- Prices for 1 package (10 syringes) of Bicillin L-A 1.2 miu/2 ml
-Publix: $776.42 with coupon
-Wal Mart: $784.93 with discount
-Target: $788.37 with coupon
-Walgreens: $788.88 with coupon
Follow-up: If no significant improvement in 3-4 days, patient should return for reevaluation or follow-up with primary physician.
Education:
1. Immediately call office if the pain becomes more severe or if dyspnea, drooling,
difficulty swallowing, and inability to fully open mouth develop
2. Increase fluid intake
3. Do not return to school for a full 24 hours
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pediatric soap note