Cardiovascular S1 and S2 heart tones auscultated No murmur heard on exam

Cardiovascular s1 and s2 heart tones auscultated no

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Cardiovascular: S1 and S2 heart tones auscultated. No murmur heard on exam. Regular rate and rhythm noted. Respiratory: No use of accessory muscles noted. No adventitious lung sounds auscultated. Nonlabored respirations. Equal chest rise and fall. Gastrointestinal: Bowel sounds present x 4 quadrants. Soft nontender. No hepatosplenomegaly noted with palpation. Breast: Deferred. Genitourinary: Deferred Musculoskeletal: Full ROM in all extremities, Gait steady. No weakness noted. Neurological: Alert and oriented. Shy, but answers questions appropriately. Posture erect when asked to sit up. Behavioral/Psychiatric: No behavioral issues or concerns noted on exam. Pediatric/Adolescent Assessment Tools: N/A- completed at 3 year well check Present Developmental: Stage 2 Autonomy vs. Shame and Self-Doubt. Patient is sitting on exam table curious about surroundings. Fear noted when new people walk in especially during rapid strep and CBC. Easily calmed by mother. Lab and/or Diagnostic Tests: Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
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Pediatric SOAP Note CBC- leukocytosis (WBC 18), 17 at prior visit 2 days ago Rapid strep- positive DIAGNOSIS 1. Streptococcal pharyngitis- J02.0 Group A strep pharyngitis is an infection of the oropharynx caused by S. pyogenes . S. pyogenes are gram- positive cocci that grow in chains. They exhibit β -hemolysis (complete hemolysis) when grown on blood agar plates. They belong to group A in the Lancefield classification system for β-hemolytic Streptococcus , and thus are called group A streptococci (CDC, 2018). Classic clinical manifestations often include sudden onset sore throat, fever, and Odynophagia. Other symptoms often seen in strep throat include headache, nausea and/or vomiting, and abdominal pain. Physical exam often exhibits pharyngeal and tonsillar erythema, tonsillar hypertrophy with or without exudates, palatal petechiae, and anterior cervical lymphadenopathy (CDC, 2018). 2. Scarlet fever, uncomplicated- A38.9 Scarlet fever is a syndrome characterized by exudative pharyngitis, fever, and bright red exanthem. It is caused by streptococcal pyrogenic exotoxins types A, B, and C produced by group A beta-hemolytic streptococci (GABHS) found in secretions and discharge from the nose, ears, throat, and skin. Scarlet fever may follow streptococcal wound infections or burns, as well as upper respiratory tract infections (Sotoodian, 2019). Scarlet fever typically evolves from a tonsillar/pharyngeal focus, although the rash develops in less than 10% of cases of strep throat. Patients and parents of children must be instructed to complete the entire course of antibiotics, even if symptoms resolve. They should be advised to follow general good hygiene precautions, especially in households with other small children (Sotoodian, 2019). 3. Acute pharyngitis- J02.9 Examination of patients who present with sore throat may reveal tonsillitis, tonsillopharyngitis, or nasopharyngitis. The absence of pharyngeal inflammation or the presence of rhinorrhea is much more likely to be associated with viral infection. However, no physical findings clearly separate group A beta-hemolytic streptococci (GABHS) from viral, other bacterial, or noninfectious causes (Simon, 2018). The primary
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