week 3

STUDENT NAME:

DATE OF ASSIGNMENT: 05/11/2020

Patient Initials: J.T.

Date of Encounter: 05/06/2020

Sex: Male

Age/DOB/Place of Birth: 12yo, DOB: 05/03/2008, Miami, FL

SUBJECTIVE

Historian: Patient J.T.

Present Concerns/CC: “My throat has been hurting recently”

Reason given by the patient for seeking medical care “in quotes”

Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care;

Sports/physical activity; Developmental Hx)

Patient is sexually inactive, a student at a local middle school, spends his time at home due to the COVID-19 pandemic, otherwise he enjoys playing videogames with his friends all day. The patient spends all of his time at home recently due to the pandemic but would otherwise go out with her family and friends sometimes.

HPI: (must include all components - OLD CARTS)

Patients throat began to hurt 2 days ago. It worsened over the past day, but he states that it is now around the same as yesterday. He states that he can still swallow food and drink, but it hurts when it passes his throat. It is present at all times of day, from when he wakes up, to when he goes to bed. The pain is localized at the back of this throat. It is dull and described as a 3/10. His mother has given him a honey and lime mixture that he states helps for a short while.

Medications: (List with reason for meds)

Patient not currently taking any medication

PMH:

Allergies: Dog hair, cat hair

Medication Intolerances:

None

Chronic Illnesses/Major traumas:

None

Hospitalizations/Surgeries:

None

Immunizations: All vaccines up to date with the exception of the most recent influenza vaccine.

Family History (please identify all immediate family)

Mother: 32 years old, no current health problems

Father: 34 years old, no current health problems

Social History (Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status)

Middle school student. Does not work. Lives with his parents and 2 brothers, one 6, the other 2 years old. Parents are married. Does not drink alcohol. Does not use recreational drugs, does not use tobacco products, does not smoke, does not vape. The patient states feeling safe at home with his family.

Review of Systems (ROS)

General

Denies fevers, chills, nausea, and vomiting

Cardiovascular

Denies chest pain, pressure, palpitations

Skin

Denies lesions, itching, or redness.

Respiratory

Denies shortness of breath, denies cough, denies difficulty breathing

Eyes

Denies blurred vision, denies visual loss, denies double vision

Gastrointestinal

Denies nausea and vomiting, denies abdominal pain, denies diarrhea, and bloody stools.

Ears

Denies hearing loss, pain, or drainage

Genitourinary/ Gynecological

Denies painful urination, denies increased frequency

Nose/Mouth/Throat

Positive for throat pain 3/10. Positive for some difficulty swallowing Denies congestion, denies discharge, denies mouth pain.

Musculoskeletal

Denies pain, denies limited range of movement.

Breast

N/A

Neurological

Denies numbing or loss of sensation, denies headache or dizziness, denies syncope, paralysis, or ataxia

Heme/Lymph/Endo

Denies anemia, bleeding or bruising, denies enlarged nodes. Denies change in temperature sensitivity.

Psychiatric

Denies anxiety, or depression. Denies mood swings, denies insomnia

OBJECTIVE (plot height/weight/head circumference along with noting percentiles)

Attach growth chart

Weight 98 lbs.

Around 73rd percentile

Temp 98.1 F

BP 113/78 bp

Height 61 inches, 5’1”

Around 92nd percentile

BMI: 18.5

Growth chart at bottom of SOAP Note

Pulse 89 bpm

Resp 17 rr

OBJECTIVE (Physical Examination)

General Appearance and parent-child interaction

Patient looks well groomed, and in no obvious distress. He came with his mother today and their interaction seems normal, there are no signs of abuse or fear.

Skin

Skin around the nose, eyes, and mouth is normal for age. No presence of comedones, or papulopustules. No cyanosis, clubbing or bruises.

HEENT

Head is normocephalic, atraumatic. Eyes: PERRLA, no conjunctival or scleral infection. Ears: bilateral TM’s pearly grey with positive light reflex. Neck: supple, full ROM. Mouth/Throat: Throat is visibly red, and inflammatory. No presence of blood detected. oral mucosa pink and moist, dental caries, gag reflex present.

Cardiovascular

S1, S2 heard, normal rate, normal rhythm, 2 sec capillary refills, no murmurs, no gallops, no palpation, no edema.

Respiratory

Lungs clear to auscultation bilaterally anteriorly and posteriorly, normal respiratory effort. No rales, no Ronchi, No wheezing

Gastrointestinal

Soft, tender to palpation. No masses. Bowel sounds present in all four quadrants. No ascites, no splenomegaly, no hepatomegaly. No rebound, no guarding

Breast

N/A

Genitourinary

No CVA tenderness. External genitalia assessment deferred.

Musculoskeletal

Normal gait and ROM. No rigidity, no deformities. No atrophy

Neurological

Normal tone, no local findings

Psychiatric

No depression or anxiety, no insomnia.

In-house Lab Tests – document tests (results or pending)

Rapid strep antigen test- Negative for strep throat

Throat culture – pending results

Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents (HEADSSSVG Assessment)

Tanner Stage 2. When asked, the patient states that he has begun to grow some pubic hair, and his voice has been cracking lately. This is characteristic of the early stages of puberty at Tanner stage 2. (Emmanuel & Bokor, 2019).

HEADSS Assessment (Katzenllenbogen, n.d.)

H- Lives with his parents in Miami, FL. Has lived at their current house for 2 years. Has no pets. The patient feels safe at home and in his neighborhood. There are no weapons at home

E- Goes to school at a local middle school. Taking online classes due to COVID-19 pandemic. The patient has good grades and feels safe at school. He is unsure of what life he wants to lead.

A- Plays videogames with his friends mostly. He goes out with his parents and brothers sometimes before the pandemic.

D- He states that he has never been in contact with or ever experienced being around anyone with drugs of any kind.

S- The patient states that he has never thought about or ever tried to commit suicide. He has never felt depressed.

S- The patient states that he has never had sex. He has never been sexually abused by anyone in his family or any strangers.

ASSESSMENT (Diagnosis – 3 Differentials and Primary)

· Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials)

· Document Evidence based Rationale for ROS and each differential with pertinent positives and negatives

· Primary diagnosis

· Is #1 on list of differentials

· Evidence for primary diagnosis should be supported in the Subjective and Objective exams.

1) Acute pharyngitis, unspecified (J02.9) The most likely diagnosis is a sore throat. It can be caused by many things including colds, the flu, or bacterial streptococcus (Pharyngitis, n.d.). In this patient’s case, it is likely a common cold.

2) Pain in throat (R07.0) The patient has pain in his throat that causes difficulty swallowing.

3) Streptococcus unspecified (B95) Although the rapid antigen test was negative. It is not 100% conclusive. A throat culture was ordered to confirm if the rapid antigen test was a false negative. Strep throat cannot be ruled out here (Strep throat, 2018).

PLAN including education

PLAN including education

· Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature.

· Include EB rationale for all aspects of your treatment plan:

· Vaccines administered this visit

· Vaccine administration forms given

· Medication-amounts and mg/kg for medications

· Laboratory tests ordered

· Diagnostic tests ordered

· Patient education including preventive care and anticipatory guidance 9 Non-medication treatments Follow-up appointment with detailed plan of f/u

Treatment:

I will not be prescribing any antibiotics or medications to this patient. Antibiotics are used for treating bacterial infections, and until the throat culture returns, there is no evidence for an infection. I recommend the patient to gargle a warm water, salt mixture whenever the pain intensifies. Throat candies may also help, they are sold at most convenience stores. The patient can also drink warm liquids such as tea, or even very cold liquids to soothe his throat (Pharyngitis, n.d.). If any other symptoms arise, bring the patient back to the clinic as soon as possible to re-evaluate. Follow up in 5 days to review results of the throat culture.

References

Emmanuel, M., & Bokor, B. R. (2019, May 13). Tanner Stages. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK470280/

Katzenellenbogen, R. (n.d.). HEADSS: The "Review of Systems" for Adolescents. Retrieved May 3, 2020, from https://journalofethics.ama-assn.org/article/headss-review-systems-adolescents/2005-03

Pharyngitis - sore throat: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved May 11, 2020, from https://medlineplus.gov/ency/article/000655.htm

Strep throat. (2018, September 28). Retrieved from https://www.mayoclinic.org/diseases-conditions/strep-throat/symptoms-causes/syc-20350338