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. 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): 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 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