Identification
Full Name : P.K.
Date & Time: 2/27/2023– 11:00 AM
DOB: 12/07/06
Location: 14715 70th Rd, Flushing, NY 11367, Dr Hurwitz
Religion: Jewish
Source of Information: Self and Father
Reliability: Reliable
Mode of Transport: Brought in by Father
CC “my throat is sore” x 1 day
16 y/o male with a past medical history of ADHD complains of a 7/10 sore throat that started yesterday. Pt notes that the pain was at its worst this morning and is aggravated more when he swallows liquids and solid food. Pt took Tylenol and drank hot tea to some relief. Pt denies sick contacts in the house but notes other students in his classes are sick. He is not sure exactly what illness they have. Pt denies fever, cough, fatigue, or inability to swallow.
PMH
ADHD
Immunizations: Up to date
Last influenza shot: October 2022
Pt denies COVID vaccine
Past surgical history
Denies past surgeries
Medications
Vyvanse 30mg, BID, Oral – Reason: ADHD
Allergies
Pt denies drug, environmental, animal, and food allergies.
Family history
Mother – 39 y/o, denies any chronic medical history
Father – 40 y/o, denies any chronic medical history
Social history
Pt denies recent travel
Pt notes his diet is well-balanced consisting of fruits, vegetables at school
Pt denies recent change in sleep habits. Pt notes 7-8 hours of sleep each night
Pt is normally physically active and plays well at school
Review of Systems
General: Denies recent weight loss or gain, loss of appetite, generalized weakness/fatigue, fever, chills, night sweats
Skin, Hair, nails: Denies skin changes, dryness, erythema, pruitis or changes in hair distribution
Head: Denies headaches, dizziness, or recent head trauma.
Eyes: Denies pain, redness, lacrimation, photophobia, pruritus or other visual disturbances.
Ears: Denies pain, discharge, or tinnitus.
Nose/sinuses – Denies discharge, epistaxis or obstruction.
Mouth/Throat – Pt ℅ sore throat but denies voice changes, ulcers, or tonsillar swelling. Pt notes normal dental exam 6 months ago.
Neck – Denies swelling or decreased range of motion.
Pulmonary system – Denies dyspnea/dyspnea on exertion, cough, or wheezing.
Cardiovascular system – Denies chest pain, palpitations or syncope.
Gastrointestinal system – Denies loss of appetite, dysphagia, abdominal pain, diarrhea, constipation, hematemesis or hematochezia.
Genitourinary system – Denies dysuria, polyuria/oliguria, urgency or hematuria.
Nervous – Denies headache, trauma, loss of consciousness, seizure activity or developmental delays.
Musculoskeletal system – Denies muscle/joint pain, weakness, swelling or recent trauma.
Psychiatric – Denies any recent changes of mood or thoughts of suicide.
Physical Exam:
Vitals
BP: 116/72
Heart Rate: 70
Respiration: 16 breaths per min
Temperature: 98.7 orally
Height: 62 in
Weight: 115 lbs
BMI: 21.0
General: 16 y/o male appears his age, well groomed and has good posture. Pt is A/O x3 and is not in acute distress
Skin: No rashes, masses, lesions, bruising or scarring throughout the exam. Skin is warm with good turgor and texture
Head: Normocephalic, atraumatic, and symmetrical. Non tender to palpation throughout with no lesions, masses, or facies noted. No nits, lice or seborrhea of the scalp.
Nails: No clubbing, masses, lesions, or signs of infection/inflammation. Capillary refill <2 on all digits.
Eyes: Pupils are symmetrical and equal round and reactive to light. Red reflex is present bilaterally with full visual fields and intact EOMs. No evidence of strabismus.
Ears: Symmetrical and appropriate in size. No lesions, masses, ulcerations, or signs of trauma. No swelling of mastoid area. No foreign bodies, discharge or effusion noted. Tympanic membrane is pearly gray and cone of light is at the appropriate position for both ears b/l without bulging.
Nose: Symmetrical and no masses, lesions, signs of trauma or discharge noted. Nares are patent bilaterally and nose is non tender to palpation. Mucosa is pink and moist without polyps or foreign bodies. Nasal septum is midline.
Sinuses: Non tender to palpation over bilateral frontal, ethmoid and maxillary sinuses.
Mouth: Oropharynx is mildly injected without exudates and no tonsillar swelling. Uvula is midline. Palate is intact and appears well hydrated with good dentition. Lips are pink and moist with no signs of cyanosis. Oral mucosa is pink and moist without any lesions or ulcerations noted.
Neck: Neck is supple. Trachea is midline with appropriate size, shape, symmetry and ROM. No masses, lesions, ulcerations, or pulsations. Thyroid is non tender with no thyromegaly or lymphadenopathy.
Thorax: Symmetrical, atraumatic and non-tender chest wall throughout. Trachea is midline with no masses or lesions noted. Respirations are unlabored.
Pulmonary: Clear to auscultation and percussion bilaterally. No adventitious sounds noted and symmetrical rise and fall of the chest bilaterally.
Cardiovascular: Regular rate and rhythm with normal S1 and S2 sounds. No JVD, murmurs, S3, S4, or splitting of heart sounds or friction rubs. Carotid pulses are 2+ bilaterally without bruits.
Abdomen: Soft, non-distended, non-tender to palpation and tympanic throughout. No guarding, rebound or hepatosplenomegaly. No scars, striae or pulsations noted. Normoactive bowel sounds in all 4 quadrants.
Musculoskeletal: No soft tissue swelling, tenderness or crepitus noted. Full range of motion in all extremities bilaterally. 5/5 strength and reflexes are 2+ bilaterally throughout.
Differential Diagnosis:
URI – an upper respiratory infection can manifest as a sore throat. I would perform a rapid strep test and a flu test as Influenza Type B has been prevalent in the neighborhood recently. I would also send out a throat culture. Assuming those are all negative I would classify this as a URI. I would advise the patient to hydrate and use throat lozenges. I would advise the patient to call back in 2 days if symptoms worsen.
Strep pharyngitis – this patient has a score of 2 on the Centor Criteria (sore throat, absence of cough). I would run a rapid strep test as well as a throat culture. Assuming either of the two are positive, I would prescribe amoxicillin 500mg BID x 10 days. I’d also advise the patient to call back if symptoms worsen.
Covid – Patient has a sore throat which may be a symptom of Covid. I would run a rapid Covid test as well as a PCR. Pt may have been exposed to Covid at school and denies taking the Covid vaccine. I would advise the patient to watch for worsening symptoms such as fever, cough, fatigue, nausea and vomiting. I would recommend Tylenol or Motrin for symptoms and watchful waiting. If necessary, rest at home and do not go to school. Follow school protocols on quarantine.
Epstein-Barr Virus (Mono) – Prevalent in this patient’s age group and possible exposure from high school. Mono can present with a sore throat as well as many other symptoms.
Assessment
16 y/o male with a PMH of ADHD, not COVID vaccinated, is brought in by his father ℅ of a 7/10 sore throat for 1 day that is temporarily relieved by tea and tylenol. Patient likely has pharyngitis due to a viral URI.
Plan:
- Test the patient for strep throat using a rapid strep test. Also do a throat culture. (If rapid strep is positive, prescribe amoxicillin 500 BID x 10 days)
- Test the patient for flu and covid if the parents are concerned and child needs to return to school
- Advise patient to treat symptomatically with tylenol, motrin and throat lozenges
- Advise patient and parents to call back if symptoms are not improving or getting worse in the next two days. Let parents know we will call tomorrow with the strep culture results.
