Age: 6

Gender: Male
Ethnicity: Caucasian
SUBJECTIVE

Chief Complaint:

"Sore throat and fever for 3 days."

Historian: Mother

History of Present Illness:

This is the case of the 6-year-old male accompanied by his mother came in to the clinic
complaining of sore throat and fever for 3 days. He 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 “sore throat”
Alleviating and aggravating factors: Pain in throat is worse when the patient ties
to eat or swallow anything. It is also worse when he wakes up first thing in the morning and at
bedtime. Mother states she had been giving him OTC Children's Tylenol 12.5ml every 4 hours as
needed for his fever.
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.

PMH: No chronic health problems

Surgical History/ Previous Hospitalization: None
Current Medications: Not on regular medication.

Immunization Record:
Up to date on all vaccines. Mother states he did receive a flu vaccine last year and will receive
one this year.

Medications: Mother states she has been giving OTC Children’s Tylenol 12.5ml every 4 hours as
needed for pain.
Family History:
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 Il diabetes.

Nutritional Screening:
Mother states that patient eats cereal with 2% milk in the mornings, eats a snack before
lunch such as a granola bar, or nuts, and usually eats school food for lunches or leftovers at
home. Mother states she usually cooks grilled lean meats with vegetables and a starch each night
for dinner. She does admit that he sneaks unhealthy snacks at times and will find packaging in
his room.

Health Maintenance:
Good compliance with annual check-ups with previous pediatrician; has an appointment
for Wellness exam October 2019. 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.

Developmental Milestone of a 6 year old male :

Emotional/Social Changes

Show more independence from parents and family.

Start to think about the future.
Understand more about his3 or her place in the world.
Pay more attention to friendships and teamwork.
Want to be liked and accepted by friends.

Thinking and Learning

Show rapid development of mental skills.

Learn better ways to describe experiences and talk about thoughts and feelings.
Have less focus on oneself and more concern for others.

Social/Emotional: He has a bestfriend his cousin who is a 7 yrs old.

Social History: Patient lives with his parents together with 2 older brothers.
Travel History: Denies any travel
Childhood Disease: Unremarkable
Allergies: NKA

Review of System

General: Mother reports fever, fatigue, and decreased appetite. Denies difficulty sleeping, chills,
malaise, night sweats, unexplained weight loss or weight gain.
Skin: Mother denies itching, urticaria, 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.
HEENT
Head: Denies headache
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 2018 and
exam was reported normal (20/20 vision).
Ears: complaining of ear pressure, denies hearing loss
Nose: No nasal congestion, epistaxis
Throat & Mouth: Mother reports sore throat. Patient states his throat hurts really bad when he
swallows, and his throat feels raw. denies hoarseness, vertigo, sinus problems,
Mouth: no dental problems, no oral lesions,
Neck/Lymph Nodes: No enlargement/tenderness

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, chestpain,
palpitations, dyspnea, activity intolerance and edema

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.

Hematologic: No bruising/ no previous BT

Gastrointestinal: Mother reports patient has a decreased appetite. He complains of pain when he
swallows. 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.

Genitourinary: Mother denies urgency, frequency, dysuria, suprapubic pain, nocturia,

incontinence, hematuria, history of stones.

Musculo-skeletal:
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.

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.

Hematologic/Lymphatics:
Mother denies unusual bleeding or bruising, lymph node enlargement or tenderness, fatigue,
history of anemia, blood transfusions.

Neurological
Mother denies headache, weakness, numbness, tingling, memory difficulties, involuntary
movements or tremors, syncope, stroke, seizures, paresthesias.

Psychiatric:
Mother denies nightmares, mood changes, anxiety, depression, nervousness, insomnia, suicidal
thoughts, exposure to violence, or excessive anger.

OBJECTIVE:
Physical Exam: Healthy appearing, well-nourished, and well-developed.

Vital Signs: Temp 98.6, BP 100/68, HR 74, RR 20, 02 sat 100%,

Height 4' 11.5" (91" percentile), Weight 79lbs (59th percentile), BMI 15.7 (24th percentile)

General appearance: Active, awake, alert, good tone, good suck, good cry not in distress.

Skin: No scaling or breaks on skin, face, neck, or arms. No skin or subcutaneous tissue masses
present, no tenderness, skin turgor normal.

HEENT:
Head: normocephalic,
Eyes: sclerae white. Conjunctivae pink. Pupils are PERRL, 3 mm bilaterally. Extraocular
movements intact.
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.
Tonsils 2+ bilateral, no exudate present. No lesions, ulcers, or masses present.

Neck: No evidence of nuchal rigidity, ROM intact. No lymphadenopathy

Respiratory: Uneventful and unlabored. Clear to auscultation bilaterally with no wheezes, rales,
or rhonchi.
Cardiovascular: S1, S2. Regular rate and rhythm, no murmurs, gallops,or rubs.
Carotid Arteries: normal pulses bilaterally, no bruits present. Pedal Pulses: 2+ bilaterally.no
cyanosis, clubbing, or edema, less than 2 second refill noted.
Abdomen: soft and nontender to palpation, nondistended. No rigidity or guarding, no masses
present, BS present in all 4 quadrants.

Genitals: deferred
Extremities: Symmetrical, no edema or lesion, pulses full and equal, no gross deformities
able to move all extremities with no limitations.
Musculoskeletal: joint stability normal in all extremities, no tenderness to palpation

Neurological: Grossly oriented x3, communication ability within normal limits, attention and
concentration normal. Sensation intact to light touch, gait within normal limits.

Psychiatric:Judgment and insight intact, rate of thoughts normal and logical. Pleasant, calm,
cooperative. Patients appears to be happy and content.

DIAGNOSTICS
Rapid Strep Group A Test
Results: Strep Test - Positive

ASSESSMENT

Differential Diagnosis 2x
Final Diagnosis

PLAN

Pharmacologic Treatment/ Non pharmacologic treatment

Start pt on Zithromax 100mg/5ml 1 ¼ tsp day 1, then ¾ tsp days

Pt can continue Tylenol prn for pain.

Prescription given for Azithromycin 200mg/5ml, take one teaspoon twice daily for ten days.

Show calculations

Saltwater gargles, drink plenty of fluids, avoid contact with others, wash hands frequently, get
plenty of sleep
Disposition
Follow up: If no significant improvement in 3-4 days, patient should return for re-
evaluation or follow up with primary physician.

Patient Teachings

1. Immediately call office if the pain becomes more severe or if dyspnea, drooling, difficulty
swallowing, and inability to fully open mouth develops
2. Increase fluid intake
3. Do not return to school for a full 24 hours
4. Replace toothbrush

Anticipatory Guidance

Always wear seat belt while in a vehicle, wear safety helmet while riding bicycle, never talk to
strangers, and need a plan for fire safety. Stressed importance of participation in daily exercise;
limit electronics to one- two hours per day. Eat a well-balanced diet, limit soft drinks and sugary
drinks, and drink plenty of water. Take a bath or shower daily, brush teeth twice daily, floss at
least once daily.

REFERENCES

Chan T. V. (2010). The patient with sore throat. The Medical clinics of North America, 94(5),
923–943. https://doi.org/10.1016/j.mcna.2010.06.001

Belfer, J.A. (May 2018). Case 2: Sore Throat and Dysphagia in a 6-year-old Boy. Pediatrics in
Review, 39, 260 - 260.
Barash, J. (March 2009). Group A streptococcal throat infection – to treat or not to treat? Acta
Pædiatrica, 98.

Articles

Homme, J. (2019). Acute Otitis Media and Group A Streptococcal Pharyngitis: A Review for the
General Pediatric Practitioner. Pediatric annals, 48 9, e343-e348 .
Ilyenko, L.I., Garashchenko, T.I., & Payganova, N.E. (2022). Current trends in the treatment of
acute tonsillophayngitis in children.