ENT Case Study

SUBJECTIVE

This 9-year-old black girl was well until yesterday morning, when she awakened with fever and sore throat.  Mother states her temperature was 99.6 orally at noon yesterday, 100.6 at about
8 p.m., and 101.2 this morning.  Temperature comes down with Tylenol but then shoots up again.  Sore throat has become increasingly severe, and today the child will not swallow anything.  She also complains of pain in the right ear on swallowing.  She is not coughing and has had no rhinitis or GI symptoms.  Past medical history is negative.  She has no known allergies.  Some of the other kids at school have been out with strep.

OBJECTIVE

Examination shows a normally developed, chubby child in moderately severe distress.  She is crying.  Oral temperature is 102.4, pulse 108, respirations 28.  The skin is hot and moist.  There is no rash.  The pharynx is diffusely edematous and deeply injected, and a small amount of exudate is noted over the tonsils.  No ulcers are noted, and the oral mucosa is normal.  There are large, tender nodes in the jugulodigastric areas bilaterally, and a few small nontender posterior cervical nodes are palpable as well.  The ear canals are clear.  The tympanic membranes are flat and gray.  Hearing is grossly normal bilaterally.  Heart is regular without murmurs or clicks.  Lungs are clear to auscultation.  The abdomen is soft and nontender, without masses or organomegaly.  A streptococcal screen in the office is positive.

ASSESSMENT

Acute streptococcal pharyngitis.

PLAN

1. Penicillin V potassium 250 mg per teaspoonful to be taken in a dose of 1 teaspoonful q.i.d. x10 days.

2. Tylenol up to 1 g q.4h. for pain and fever.

3. Encourage oral fluids, soup, pop, Popsicles.

4. Hot saline gargles p.r.n. for throat pain.

5. Mother is to call in, in 24 hours, to report progress.

6. Mother is reminded not to give ASA.

FOOTNOTE

Lines 3-22.  Alternative:  Transcribe in SOAP format.

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