RESPONSE DISCUSSION

Marcus is an 8-year-old with a 36-hour complaint of headache (frontal), sore throat, fever to 102°F, and nausea. Mom says his appetite is decreased and his breath smells “like a puppy dog’s.”

PMH: A Polish 8-year-old boy, in mild distress. HEENT: Tympanic membranes partially obscured by cerumen but in neutral position and transparent, 2+ enlarged and red tonsils with exudate, strawberry tongue, and petechiae on the soft palate enlarged tonsillar and anterior cervical lymph nodes. CV: RRR PULM: Clear to auscultation bilaterally

What additional questions will you ask?

By utilizing the LOCATES mnemonic in this case, we obtain the location of the problem related to the headache and sore throat. Onset is another area that is discussed since the problem started 36 hours ago. The character of the pain can be asked. How is your pain? does the pain comes and goes? does the pain let you sleep at night? Describe the pain for me please? Associated sign and symptoms are given, but more can be asked. Fever, decreased appetite and the puppy dogs smell on the breath are some of the associated symptoms already provided. Questions such as the presence of diarrheas, abdominal pain or vomiting should be asked of the parent. At what time of the day is the fever? Is headache present or more intense. Other questions are related to alleviating factors, any medication given to the child since the beginning of the symptoms? What makes the headache/sore throat better? What makes it worse? Radiation of the pain should be investigating with questions such as `Do you have pain somewhere else?’ `Do your ears hurt?’ Finally, we can ask the child `how intense is the pain?’, we can ask the child to rate the intensity of the pain he is feeling (Sullivan, 2019). Other questions such as is `anyone sick at home or school recently?’ `Does the child have any medical problems?’ `Is he currently taking any medications?’ `Does he have any medication, food or environmental allergies?’ `Are there any pets at home?’ `Is the home carpeted?’

What additional examinations or diagnostic tests, if any will you conduct?

Other physical examinations I would perform is on the skin, looking for any rash (scarlet fever rash) that would help me confirm my diagnosis. Other vital signs are important in order to treat since pediatric doses are usually weight based. considering the clinical findings of the physical assessment I would perform the following tests:

1. Rapid antigen Streptococcus test (RAST) , which is a quick test and compared to a throat culture it has a 96% specificity and 86% sensitivity, but we must take into consideration sensitivity varies by the type of kit we are using (Domino, Baldor, Golding, & Stephens, 2019).

2. Blood agar throat culture from swab, which is the gold standard in diagnosing an infection by Group A streptococcus bacteria with a 90-95% sensitivity. This type of culture is recommended for children with negative RAST due to higher likelihood of complications (Domino, Baldor, Golding, & Stephens, 2019).

3. Modified Centor clinical prediction rule for group A streptococcal infection:

  +1 point for tonsillar exudates

  +1 point for tender anterior chain cervical adenopathy.

  +1 point for absence of cough

  +1 point for presence of fever by history

  +1 point for age <15 years old

The scoring scale established that, for a total of 4 or more points, a positive predictive value of approximately 80% and we should treat empirically, 2-3 points is a predictive value of 50% and should be combined with a positive RAST result in order to treat empirically. 0-1 points is a less than 20% predictive value and RAST should not be performed, not treatment with antibiotics should be started, only follow up as needed (Domino, Baldor, Golding, & Stephens, 2019)

What are your differential diagnoses? What historical and physical exam features support your rationales? Provide at least 3 differentials.

1-      Strep throat (bacterial Pharyngitis): This is the most likely diagnosis taking into considerations the clinical findings of the physical assessment such as +2 enlarged and red tonsils with exudate, enlarged tonsillar and anterior cervical lymph nodes, elevated fever of 102 F. Having clear lung sounds and lack of coughing is consistent with the mentioned diagnosis. A positive RAST will indicate the presence of GABHS or GAS (group A beta hemolytic streptococcus) and antibiotic treatment is granted. Other physical examinations suggesting infections with GABHS is the presence of petechias in the soft palate and bad breath (Burns, et al., 2017). In this patient the presence of strawberry’s tongue may indicate a previous exposure to GAS (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017).

2-      Infectious mononucleosis: This disease typically produces ”headache, fatigue, high fever, pharyngeal erythema, tonsillar hypertrophy, white to gray-green exudate, petechias at the junction of the soft and hard palate and posterior cervical adenopathy” (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017). The authors also mentioned hepatomegaly and splenomegaly to be present in less than 50% of the cases and the presence of jaundice being even less probable. This is a less likely diagnosis because it is usually seen in adolescents and young adults. If this diagnosis is suspected a laboratory CBC should be ordered and the presence of leukocytosis with atypical lymphocytes should be present, also sore throat is not between the first symptoms to appear (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017).

3-      Viral Pharyngitis: With this diagnosis the patient may present with symptoms of fever, cough, nasal symptoms and nasal erythema with little to no pharyngeal exudate. The pharynx may appear boggy, swollen or pale. Painful lymphadenopathy is not usually present (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017). Epstein-Barr Virus (EBV), “a lymphocrytovirus and a member of the γ-herpesvirus family, infects at least 90% of the population worldwide, the majority of whom have no recognizable illness” (Henry H Balfour, Dunmire, & Hogquist, 2015). The authors define this virus as the main cause of infective mononucleosis. EBV can produce exudate on the tonsils, soft palate petechiae, and diffuse adenopathy (Burns, et al., 2017).

 

 

How will you treat this child?

For the treatment of the fever, malaise, sore throat we can prescribe:

· Tylenol 10-15 mg/Kg orally every 4-6 hours alternate with

· Ibuprofen 10 mg/kg orally every 6 to 8 hours

For the treatment of the infection by GABHS

· Penicillin V potassium: (since there is no information on the child’s weight)

· For children up to 27 Kg. 250 mg orally three times daily for 10 days

· For children over 27 Kg. 500 mg orally three times daily for 10 days

       For the supportive care

· Fluids and rest

Patient Education, Health Promotion & Anticipatory guidance:

· Repeat culture is usually not necessary

· Continue with antibiotic treatment till the end of the prescribed doses even if the symptoms subside.

· Fomites such as bathroom cups, toothbrushes and orthodontic devises can keep GABHS and should be cleaned or discarded.

· Children can return to school when they are afebrile and taking antibiotics for at least 24 hours (Burns, et al., 2017).

On the Polish culture pain is seen as a punishment from God.  They believed in biomedical and natural causes. They may use herbal treatment and folk remedies to treat diseases, but they have trust in physicians and take medications as ordered when needed. Self-care treatments are applied before seeking medical help (The Polish National Home Association, 2019).

Health Promotion:

This child must have had all his vaccinations up to date with 3 doses of Hep B, 5 doses of DTaP, 3 doses of IVP, 4 doses of Pneumococcal vaccine, 4 doses of HIB, 3 doses of rotavirus, Influenza vaccine yearly after 6 month of age, 2 doses of MMR, 2 doses of Hep A, and 2 doses of varicella.

This child next well visit will be at age 9 years old. His next set of immunizations are due at age 11 when he will receive Tdap, meningococcal and HPV vaccines.

What additional anticipatory guidance should be provided today?

· At this age parents should extend freedoms to their children and give them new responsibilities.

· Children should be enrolled in after-school activities to help with self-esteem, improve academic performance and better grades as well as less chance to get involve in alcohol and drugs consumption and other risky behaviors.

· Children should be encouraged to participate in daily exercise.

· Limit participation in activities that involves TV, video games and computer time.

· Stablish an eating routine with at least 3 nutritious meals and 2 nutritious snacks.

· Use of booster seats or use of seatbelts.

· Usage of protective gear when riding bicycles, skateboards or scooters.

· Monitor internet and social media. Usage of tools to prevent strangers from contacting the child through internet.

· Teach and talk with children about safety.

· Provide time for the child to do homework.

· Listen to the child read aloud.

· Make home rules and apply them.

· Model positive conflict resolution and good communication.

· Get rid of firearms or make sure they are locked away.

· Supervise children near water at all times, teach them to swim.

· Recognize academic achievements to motivate further work.

· Stay involved in children school life (Burns, et al., 2017).

References

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L. (2017). Pediatric Primary Care Sixth Edition. St. Louis: Elsevier.

Buttaro, T. M., Trybulski, J., Polgar-Bailey, p., & Sandberg-Cook, J. (2017). Primary Care A Collaborative Practice Edition 5. St.Louis, Missoury: Elsevier.

Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (2019). The 5-Minute Clinical Consult 2020 28th Edition. Philadelphia: Wolters Kluwer.

Henry H Balfour, J., Dunmire, S. K., & Hogquist, K. A. (2015). Infectious mononucleosis. Clinical & Translational Immunology. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346501/

Sullivan, D. D. (2019). Clinical Documentation Third Edition. Philadelphia: F.A Davis.

The Polish National Home Association. (2019, January 4). Cultural Approaches to Pediatric Palliative Care in Central Massachusetts: Polish. Retrieved from Lamar Soutter Library, A leader In Servive And Learning: https://libraryguides.umassmed.edu/diversity_guide/polish