Child with Strep: History and Physical
Provider: Patient: D.S.
Date of Service: 26/4/2022 Date of birth: December 23, 2013
Time of Service: 1415 Age: 8 years 4 months
Race/Ethnicity: Caucasian Gender: Male
Insurance: United Healthcare PPO
Allergies: NKDA
Medication: Father states he has been giving him children’s Motrin 2 tsp (10mL) P.O. Q 6-8 hours prn and OTC Children’s Tylenol 12.5 ml after every 4 hours as required for his fever.
Chief Complaint: Patient presents with throat pain and fever, which began three days ago.
Historian: Father
History of Present Illness: D.S. is an 8-year-old male who presents to the care facility today in his father’s company with sore throat and fever complaints. Father states that D.S. began complaining of sore throat, difficulty swallowing due to pain, fever, headache, and decreased appetite three days ago.
Father reports fevers have been approximately 102F. He has been giving D.S. Motrin and Tylenol for the fever. Throat pain has remained constant for the past three days, and he rates it 3 out of 5 on the FACES pain scale. Father reports no information of any known sick contact, but they attended a football tournament for her brother during the weekend the previous week, and many people also attended the event.
Past Medical History (PMH):
Allergies: NKDA
Current Medications: Father states he has been giving him children’s Motrin 2 tsp (10mL) PO Q6-8 hours prn and OTC Children’s Tylenol 12.5 ml after every 4 hours as required for his fever.
Age/Health Status: 8 years four months/ No chronic health problems
Appropriate Immunization Status: Up to date on all vaccines; Father states the patient receives a flu vaccine every year, with the last being last year’s fall, and will receive another this year at his primary physician’s office this fall.
Dates of Illness during Childhood: N/A
Injuries: No significant injuries requiring hospitalization or medication intervention.
Hospitalizations: No hospitalizations
Surgeries: No surgeries
Health Maintenance and Health Promotion:
- Father states good compliance with annual check-ups with the pediatrician and has an appointment for June 30th
- Dental visit at least once a year; brushes at least once a day. No cavities at the last appointment, which was in January of this year. Encouraged to continue annual visits to the orthodontist.
- Father states that frequent handwashing
- Well balanced diet
- Father states that D.S. has a pediatrician he regularly sees for immunizations. No immunizations are required at this time.
- Father reports no lead exposure risks
- Father states the patient is very active; physical activity for at least 4 hours daily. The patient likes to play with balls, swim, and ride toys outside. Allowed to watch T.V. and play video games daily for two hours.
- Father states patient wears a safety belt and sits appropriately in the car. They have a home pool that has a locked gate. The patient swims under his parents’ supervision. Father has a pistol, which is kept in a locked cabinet, and the patient cannot access the keys. All medications are locked away, out of D.S.’s reach.
Family History (F.H.): The patient is the only child in the family. Father is 33 years old, and the mother is 31 years old. The father states mother has no health problems for herself. Father has no significant medical history or health problems. Maternal grandmother died when she was 58 years old after suffering from obesity, stroke, and high blood pressure for about ten years.
Maternal grandfather is 60 years old and has hypertension, and was recently diagnosed with cancer of the small intestines. Paternal grandmother is 67 and has no significant medical history or health problems. Paternal grandfather is 67 years old and suffers from type II diabetes. Maternal aunt (age 28) has no significant past medical history.
Social History: D.S. is in third grade this school year. He is active and always plays with other kids in school and outside in the driveway with neighbors’ children after school. Father states that both parents neither smoke nor drink alcohol. Patient does not drink or eat caffeine-containing foods and drinks.
He is allowed to watch T.V. and play video games for 2 hours daily. Father reports that the patient has struggled to eat due to pain when swallowing, and his appetite has decreased. He is not playful as usual and appears not to be himself since the onset of symptoms.
Growth and Development:
Physical Growth: Height and weight are appropriate with growth curves per CDC Guidelines (See Appendix B). The patient’s BMI is 16.6, within the healthy BMI range for this patient’s age group.
Motor: Fine and gross motor skills are WNL for the patient’s age.
Cognitive: The patient’s cognitive function is WNL for the patient’s age.
Verbal: Patient with normal communication for age.
Social: Patient’s social development is within normal parameters for his age.
Personality: Patient is intense, aggregable, extrovert, active, and easily distractible.
School: Patient is in third grade this school year.
Review of Symptoms:
Constitutional symptoms: Father reports fever, fatigue, energy loss, and decreased appetite. Denies malaise, night sweats, unexplained weight loss, or weight gain.
HEENT:
Head: Father reports complaints of mild headache. Denies dizziness or lightheadedness.
Eyes: Denies blurred vision, difficulty focusing, ocular pain, diplopia, scotoma, peripheral visual changes, and dry eyes. No corrective lenses. Father states the date of the last eye exam was in November of 2020, and exam results were reported normal (20/20 vision).
Ears, Nose, Mouth, and Throat: Father reports sore throat and difficulty swallowing. Denies hearing changes, earache, ear pressure, or tinnitus. Denies hoarseness, vertigo, sinus problems, epistaxis, dental problems, oral lesions, and nasal congestion. The date of the last dental visit was January of this year.
Cardiovascular: Denies any history of a heart murmur, chest pain, palpitations, dyspnea, activity intolerance, varicose veins, or edema. Father states the patient is very active and likes to play at school and outside with neighbors’ kids after school. He participates in physical activity for at least four hours daily.
Respiratory: Father denies cough. Denies history of respiratory infections, SOB, wheezing, difficulty breathing, exposure to secondary smoke, T.B., hemoptysis.
Gastrointestinal: Father reports the patient is struggling to eat and seems to have a decreased appetite since the onset of symptoms. Father reports that D.S. experiences pain when swallowing; dysphagia. Denies reflux, pyrosis, bloating, nausea, vomiting, diarrhea, constipation, hematemesis, abdominal or epigastric pain, hematochezia, change in bowel habits, food intolerance, flatulence, hemorrhoids. Father states they try to prepare healthy, well-balanced meals and feed the patient.
Genitourinary: Father denies urgency, frequency, dysuria, suprapubic pain, nocturia, incontinence, hematuria, and history of stones.
Musculoskeletal: Father denies joint pain and tenderness.Father denies back pain, muscle pain or cramps, neck pain or stiffness, and changes in ROM. Father states the patient is active for at least four hours each day. He wears his seatbelt.
Integumentary: Father denies itching, urticaria, hives, nail deformities, hair loss, moles, open areas, bruising, and skin changes. The father states they apply sunscreen while outside and inspect his skin always for any changes.
Neurologic: Father reports complaints of headache. Denies weakness, numbness, tingling, memory difficulties, involuntary movements or tremors, syncope, stroke, seizures, or paresthesia.
Psychiatric: Father reports mood changes, distress, and nervousness. Denies nightmares, anxiety, depression, insomnia, suicidal thoughts, exposure to violence, or excessive anger.
Endocrine: Father denies cold or heat intolerance, polydipsia, polyphagia, polyuria, changes in skin, hair or nail texture, unexplained weight change, changes in facial or body hair, changes in hat or glove size, and use of hormonal therapy.
Hematologic/lymphatic: Father denies unusual bleeding or bruising, lymph node enlargement or tenderness, fatigue, history of anemia, and blood transfusions.
Allergic/immunologic: Father denies seasonal allergies, allergy testing, exposure to blood or body fluids, use of steroids, or immunosuppression in self or family.
Developmental: Denies delay of gross or fine motor skills or cognitive development.
Physical Exam:
Weight: 28 kg
Height: 130 cm
BMI: 16.6
Vital Signs: Temperature 101.2; BP-104/68; HR 121; RR 20; O2 sat-99%
General Appearance: healthy-appearing, well-nourished, and a well-developed 8-year-old Caucasian male. Appears moody, tired, sick, and with no acute distress or feelings of anxiety.
Level of Distress: NAD.
Ambulation: ambulating normally.
Head: Nomocephalic/atraumatic. Symmetric. Normal hair distribution and pattern.
Eyes: Sclera white. Conjunctivae pink. Pupils are PERRL, 3 mm bilaterally. No redness or drainage was observed. Extraocular movements are intact.
Ears: External appearance normal, external auditory canals clear, no lesions, redness, or swelling; on otoscope exam, tympanic membranes clear, no redness, fluid, or bulging identified. Hearing is intact.
Nose: The nose’s appearance is normal, with no mucous, inflammation, or lesions. Nares patent. Septum is midline.
Mouth: Pink, moist mucous membranes. No missing or decayed teeth.
Throat: Soft and hard palates are intact. No lesions were noted. Pharyngitis with patchy yellow/white exudate was noted on examination. Tonsils 2+. Uvula midline and beefy red.
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. Patient is warm and dry, with no edema or cyanosis noted.
Pulmonary/Thorax: Even and unlabored. Clear to auscultation bilaterally with no wheezes, rales, or rhonchi. Breath sounds are clear throughout all lung fields.
Gastrointestinal: abdomen soft and non-tender to palpation, non-distended. No rigidity or guarding, no masses present, and bowel sound present in all four quadrants.
Genitourinary: No bladder distention, suprapubic pain, or CVA tenderness.
Musculoskeletal: Joint stability is expected in all extremities. Patient movements are symmetrical. No weakness was noted.
Integument/Lymphatic:
Inspection: 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
Neurologic: Patient is alert and oriented x4, 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, and cooperative. Patient appears distressed and nervous.
Hematologic/immunologic: Swollen and tender anterior cervical lymph nodes, no masses present, no bruising
Back: Spine is WNL with no curvature, deformities, or lesions.
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Stages of Development:
Erickson’s Stage of Psychosocial Development: Industry vs. Inferiority
The patient demonstrates appropriate behavior for this stage of development as he demonstrates a sense of pride in his achievements and abilities. He is coping well with new social and academic demands, and his parents are constantly encouraging him to believe in his abilities. He is willing to do everything to complete the tasks set before him.
Piaget’s Stage of Cognitive Development: Concrete operational stage
The patient exhibits behavior appropriate for this stage of development in that he has become more logical in his thinking, and his egocentrism is disappearing. He is concerned about other people’s perspectives and always asks questions about what his parents think about different things like his dressing, academic performance, and friends. He is a better communicator and engages in meaningful conversations, and can isolate information related to a specific situation.
Motor Sensory Development: WNL; Patient can ambulate without assistance. Reports no muscle weakness.
Developmental: Patient’s development is appropriate for his chronological age.
Lab/Diagnostic test/EKG: Rapid Strep Test: positive
Impression:
Centor score was used to estimate the possibility of acute streptococcal pharyngitis.
Centor score for patient = 5, suggestive of streptococcal infection. Scored as follows:
Absence of cough = 1
Swollen and tender anterior cervical lymph nodes = 1
Temperature >100.4 = 1
Tonsillar exudate or swelling = 1
Age 3-14 years = 1
Assessment:
- 8-year 4 months old male patient with no significant medical history, normal growth and development, presenting with sore throat and pain, difficulty swallowing, and fever.
Presumptive Diagnosis
- Strep Pharyngitis- J02.0
- Viral pharyngitis- J02.9
- Tonsillitis- J03. 90
- Mononucleosis- B27.9
- Influenza- J11.1
- Upper respiratory infection- J06.9
Differential Diagnoses
- Viral pharyngitis- J02.9
Pharyngitis refers to an inflammation of the mucous membranes of the oropharynx. It stems from an infection caused by bacteria or viruses (Wolford et al., 2021). Clinical manifestations include fever, painful cervical adenopathy, ear pain, tonsillar exudates, coughing, rhinorrhea, headache, rash, and conjunctivitis.
Refuting data: Positive strep test and Centor score of 5
- Tonsillitis- J03. 90
Tonsillitis results predominantly from a viral or bacterial infection, and patients develop a sore throat (Anderson & Paterek, 2021). Most patients present with fever, tonsillar exudates, sore throat, and tender anterior cervical chain lymphadenopathy.
Refuting data: Positive strep test and Centor score of 5
- Mononucleosis- B27.9
Symptoms of mononucleosis are similar to those of strep pharyngitis. Patients present with cervical lymphadenopathy, exudate or non-exudate pharyngitis, malaise, fever, or soft petechial (Mohseni et al., 2020). Additional complaints include headaches and poor oral intake.
Refuting data: Positive strep test and Centor score of 5
- Influenza– J11.1
Influenza is a communicable viral disease impacting the upper respiratory tract and upper and lower respiratory passages. Influenza causes patients to develop body aches, malaise, cough, congestion, rhinorrhea, and N/V/D. Patients can also present with cough, fever, sore throat, myalgia, congested eyes, headache, and runny nose (Boktor et al., 2021).
Refuting data: Centor score of 5 and positive strep test
- Upper respiratory infection- J06.9
Most patients with this infection present with fever, headache, sneezing, runny nose, congestion, sinus pain or pressure, cough, sore throat, or cough (Thomas & Bomar, 2018). Some have swollen lymph nodes.
Refuting data: Centor score of 5 and positive strep test
Confirmed Diagnosis: Strep Pharyngitis (J02.0); Given the mechanism, strep pharyngitis was confirmed. The diagnosis was made using the history and reported symptoms, including sore throat, difficulty/painful swallowing, fever, headache, and signs identified during the physical exam, including fever, enlarged tonsils, tonsillar exudates, pharyngeal erythema, anterior cervical lymphadenopathy, rapid strep test that gave positive results, and Centor score with a score of 5. Advised caregiver to follow up with primary care provider as needed. Return to the clinic urgently if new or worsening symptoms develop.
Plan:
- Discharge from hospital
- Medication
- Bicillin L-A 1,200,000 units/2ml I.M. syringe:
Inject 1.2ml by intramuscular route in the office
Brand name/generic: Bicillin L-A (penicillin G benzathine)
Indication: Group A streptococcal infection
MOA: It binds to specific penicillin-binding proteins (PBPs) inside the bacterial cell wall; penicillin G inhibits the third and last stage of bacterial cell wall synthesis. The bacterial cell wall autolytic enzymes like autolysins then mediate cell lysis.
Dose: >27kg: 1.2 million units IM x1-
Prices: for 1 package (10 syringes) of Bicillin L-A 1.2 miu/2 ml-
Publix: $776.42 with coupon
Walmart: $784.93 with discount
Target: $788.37 with coupon
Walgreens: $788.88 with coupon
- Tylenol for pain and fever
Generic name: acetaminophen
Brand names: Tylenol Ext, Little Fevers Children’s Fever/Pain Reliever, Little Fevers Infant Fever/Pain Reliever
Indication: Temporarily relieves minor aches and pains due to headache, backache, the common cold, minor pain of arthritis, toothache, premenstrual and menstrual cramps, and muscular aches, and temporarily reduces fever (Gerriets et al., 2021).
MOA: Tylenol belongs to a class of drugs called analgesics (pain relievers) and antipyretics (fever reducers). MOA is not well known, but it may minimize the production of prostaglandins in the brain (Gerriets et al., 2021). Prostaglandins are chemicals that lead to inflammation and swelling.
Dose: 12.5 ml every 4 hours or five doses in 24 hours
Prices: The lowest price is around $1.35
The average retail price is $4.02
Contradictions: Tylenol contradictions include hypersensitivity to acetaminophen, severe hepatic impairment, and severe active hepatic disease
- Non-medical remedy: plenty of fluids and rest, saltwater gargles or throat lozenges to soothe the throat
- Follow-up if pain persists in 3-4 days with the primary care provider
- Informed to return to the clinic if the patient develops new or worsening symptoms.
- Monitoring for desired clinical effects and pain relief
Billing Codes:
ICD Codes:
- Strep Pharyngitis- J02.0
- Viral pharyngitis- J02.9
- Tonsillitis- J03. 90
- Mononucleosis- B27.9
- Influenza- J11.1
- Upper respiratory infection- J06.9
Education:
- Get plenty of rest and fluids.
- Complete the entire course of medication prescribed even if the patient feels well
- Encourage hygiene, including regular and good handwashing, toothbrush change to prevent reinfection, and avoid sharing utensils.
- Call the office if the pain returns or becomes more severe, or the patient still indicates difficulties swallowing.
- Monitor and report reactions like hypersensitivity reactions, nausea, rash, or vomiting.
- Monitor return to regular activity and play, and the patient may return to school when afebrile.
No need for further lab tests at the moment.
Evidence-Based Rationale
Strep pharyngitis is commonly due to Group A streptococcus, a Gram-positive and non-motile bacterium. It accounts for 20 to 30 percent of all pediatric cases. Strep pharyngitis prevalence for patients aged 18 years and below and above five years is 37% (Ashurst & Edgerley-Gibb, 2018). Patient history can include abrupt fevers and sore throat after exposure to an individual with the disease within the past two weeks.
Physical exam findings may include cervical lymphadenopathy, pharyngeal inflammation, and tonsillar exudate. Palatine petechiae and ovular edema can also suggest strep pharyngitis (Ashurst & Edgerley-Gibb, 2018). A rapid strep test is taken to confirm the streptococcus, and if positive, there is no need for a throat culture across all age groups. Treatment involves antibiotics like penicillin/ Bicillin to treat the infection and medication, such as Tylenol, to control pain and fever.
References
Anderson, J., & Paterek, E. (2021). Tonsillitis. In StatPearls [Internet]. StatPearls Publishing.
Ashurst, J. V., & Edgerley-Gibb, L. (2018). Streptococcal pharyngitis. In StatPearls [Internet]. StatPearls Publishing.
Boktor, S. W., Hafner, J. W., & Doerr, C. (2021). Influenza (Nursing).
Gerriets, V., Anderson, J., & Nappe, T. M. (2018). Acetaminophen.
Mohseni, M., Boniface, M. P., Graham, C., & Doerr, C. (2020). Mononucleosis (Nursing). In StatPearls [Internet]. StatPearls Publishing.
Thomas, M., & Bomar, P. A. (2018). Upper respiratory tract infection.
Wolford, R. W., Goyal, A., Syed, S. Y. B., & Schaefer, T. J. (2021). Pharyngitis. In StatPearls [Internet]. StatPearls Publishing.
Appendix A
D.S. Family Medical History Genogram
Appendix B
D.S. Growth Chart
https://www.cdc.gov/growthcharts/data/set1clinical/cj41l021.pdf
Appendix C
D.S. BMI Calculation
https://www.cdc.gov/healthyweight/bmi/calculator.html
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