Patient Information:
Initials: E.F. Age: 8 years old Sex: Female Race: Caucasian
S.
CC (chief complaint): “Symptoms of the upper respiratory tract.”
HPI: E.F., an 8-year-old girl of Caucasian/White ethnicity, is accompanied by her mother to assess symptoms related to the upper respiratory tract. The patient exhibits signs of nasal congestion, pharyngitis, unproductive cough, and pyrexia. The fever manifested yesterday evening, reaching a maximum recorded temperature of 102. The patient had throat pain 24 hours ago, characterized by moderate irritation. The cough was first noticed 48 hours ago. The patient has a cephalalgia. There have been no recorded occurrences of sickness, diarrhea, or rash. The patient’s mother has not disclosed any mitigating circumstances. The patient’s medical history revealed a detrimental outcome from a self-administered Covid test performed three days ago.
Location: The head and neck
Onset: two days beforehand
Character: irritable cough with a moderate intensity
Associated signs and symptoms: fever, sore throat, nonproductive cough, and nasal congestion
Timing: worse throughout the evening
Exacerbating/relieving factors: None
Severity: 5/10 pain scale
Current Medications: The patient administers Amoxicillin 400mg/5ml oral suspension orally, taking 5 ml thrice daily.
Allergies: None
PMHx: The patient has recently been immunized. Prior diagnoses or surgical operations are not included in the patient’s medical history.
Soc & Substance Hx: The patient lives with her 12-year-old sister and parents. Her father, a 45-year-old architect, works in the family business. The patient’s mother is a nurse practitioner who is 39 years old. The mother claims to have delivered her child vaginally at 38 weeks gestation, taken prenatal vitamins regularly and had no complications throughout her pregnancy. The patient’s mother said that no drugs were used in the family. She sometimes confesses to drinking alcohol, which she safely hides and conceals. The person lives with a cat and a dog.
Fam Hx: The paternal grandpa died of cervical cancer at the age of 68. The maternal grandma, who is 77 years old, suffers from hypercholesterolemia. The client’s maternal grandpa died of a heart attack at the age of 69. Diabetes has been diagnosed in the maternal grandma, who is 63 years old. The father is 45 years old and in excellent health. The mother, 39 years old, has no known medical problems. There have been no known health difficulties with your brother.
Surgical Hx: None.
Mental Hx: The patient denies experiencing anxiety or depression. Denies ever engaging in self-harming acts or contemplating suicide or murder.
Violence Hx: None
Reproductive Hx: The patient was delivered vaginally as predicted. There were no reports of HIV/STIs.
ROS:
GENERAL: There have been complaints of mild throat pain that started a day ago and felt itchy. There have been reports of fever and headache. Denies being overweight, fatigued, or worn out.
HEENT: Eyes: denies the presence of double eyesight, yellow eye, or visual loss. Ears, Nose, and Throat: The patient has a painful throat and nasal congestion.
SKIN: denies the existence of any rash or itching.
CARDIOVASCULAR: denies experiencing chest pressure, pain, or discomfort. There is no swelling or palpitations.
RESPIRATORY: denies having breathing problems. An ineffectual cough has been reported.
GASTROINTESTINAL: claims no vomiting, constipation, or anorexia. Denies experiencing stomach pain or blood.
GENITOURINARY: denies Urinary Urgency or Burning.
NEUROLOGICAL: There has been a complaint of a headache. Denies feeling lightheaded, suffering syncope, paralysis, vertigo, or tingling in the digits. Denies any change in bladder or bowel control.
MUSCULOSKELETAL: The patient denies having stiffness, joint pain, back pain, or muscle pain.
HEMATOLOGIC: Refuses to admit bruises, bleeding, or anemia.
LYMPHATICS: Denies having a large number of nodes. There is no past splenectomy history.
PSYCHIATRIC: rejects a concern or sadness-filled history.
ENDOCRINOLOGIC: disputes heat, cold, or sweat intolerance claims. There was no polydipsia or polyuria.
REPRODUCTIVE: prevents vaginal leaking. I’m not a sexual being.
ALLERGIES: denies ever suffering from hay fever, hives, acne, or asthma.
O.
Physical exam:
Vitals: BP: 97/65, R 19, P 113, T 98: Weight: 41 lbs 0 oz. Height: 3′ 8.8″ BMI: 14.36 (75th Percentile), BSA 0.77
General: The patient is not currently at risk. Demonstrates appropriate engagement and participation during examinations.
HEENT: The individual has a typical cranial morphology and no history of physical injury—absence of discharge. The conjunctiva appears clear in both eyes. A bullous lesion is present in the right ear at approximately 11 o’clock without accompanying redness. The auditory system is generally resilient to damage. The nose does not exhibit any visible lesions, mucosal inflammation, or abnormalities in the septum and turbinates. The throat exhibits minor edema and exudates. The tonsils have become enlarged. The nostrils exhibit signs of swelling and redness. The oral cavity’s mucous membranes are moist and devoid of any lesions.
Cardiac: Consistent rhythm and rate. S1 and S2 were heard without any audible sounds of movement or friction.
Respiratory: Bilateral breath sounds are symmetrical, precise, and balanced, without rhonchi, rales, or wheezes. There is no necessity to exert additional effort to inhale and exhale.
Neck: The neck exhibits the full range of motion, is free from lymphadenopathy, and demonstrates flexibility.
Skin: Skin appears normal with no signs of rash or excessive dryness. Capillary refill time is less than 2 seconds.
Neuro: Neurological examination reveals regular and symmetrical tone and strength. Provide appropriate responses to inquiries. The speech exhibits audibility and clarity, albeit with slight slurring.
Musculoskeletal: Upper limb tension without contractile limitations. The individual maintains a stable stance, with a slight inward rotation of the left foot.
Diagnostic results: The diagnostic results indicate a positive result for the strep test swab. The recommended code for rapid streptococcal testing is 87880.
A.
Primary Diagnosis: J02.0 Streptococcal Pharyngitis
Medication: The patient initiated treatment with Amoxicillin, taking 5 ml of the 400mg/5ml oral suspension orally thrice daily. Penicillin or amoxicillin is the recommended antibiotic for treating group A streptococcal pharyngitis. Ibuprofen liquid, specifically at a concentration of 100 mg/5 ml, is utilized for treating fever as needed, as stated by Di Muzio et al. (2020).
Non-pharmacological interventions: Sore throats may be relieved by eating cold items like ice pops and drinking warm liquids like broth, tea without caffeine, or warm water with honey.
Education: To promote a favorable therapeutic outcome, provide the patient’s mother with guidance on the appropriate administration of antibiotics.
Health Promotion: Provide recommendations to the patient’s mother regarding optimal activities and dietary choices for her child. Luo et al. (2019) argue that Bright Futures for Children promotes the holistic well-being of children, with a focus on nutrition, health, safety, security, and early education from birth.
Referral: Refer the patient to an otolaryngologist for additional evaluation (Di Muzio et al., 2020).
Follow-up: After four weeks, the patient should make another visit to the clinic to assess the effectiveness of the treatment.
Reflection: Nurses are instructed to comply with the nursing code of ethics when providing care, considering various patient demographics, such as race and ethnicity, along with other factors. Regarding a minor patient, the mother is bestowed with the power to make medical decisions on behalf of her kid. Tanz et al. (2020) recommend educating the mother about appropriate antibiotic use to mitigate antibiotic resistance and improve treatment efficacy. The mother should be instructed about health promotion techniques, including the significance of maintaining a well-balanced diet, ensuring enough sleep for the kid, and engaging in regular physical exercise.
Allen, M., Meraj, T. S., Oska, S., Spillinger, A., Folbe, A. J., & Cramer, J. D. (2021). Acute epiglottitis: Analysis of U.S. mortality trends from 1979 to 2017. American Journal of Otolaryngology, 42(2), 102882. https://doi.org/10.1016/j.amjoto.2020.102882
Di Mauro, Ammirabile, Quercia, Panza, Capozza, Manzionna, & Laforgia. (2019). Acute Bronchiolitis: Is There a Role for Lung Ultrasound? Diagnostics, 9(4), 172. https://doi.org/10.3390/diagnostics9040172