reports that he likes going to school and is doing well; he also has lots of friends in school and at church. Father is a nurse; Mother is a social worker. No drugs/alcohol/tobacco use in the home. He eats regular food and sleeps well except for when he has a cold.
Immunization History:all vaccines up to dateReview of Systems: Constitutional symptoms: Positive for malaise, headache, fever, sore throat,and nochills, no night sweats or weight loss, OBJECTIVE DATA:Physical Exam:Vitals: T 101.5 orally, BP 90/60, pulse 98, RR 16, room air sat 98%, Ht 43inches, Wt 47 lbs., BMI 24.5 General: Well nourished, healthy looking young man with mild weaknessHEENT:Head normocephalic, blonde thick hair evenly distributed, Pupils equal, round, and reactive to light (3mm), no exudates, Conjunctiva pink and sclerae with no jaundice, Tympanic membranes intact bilaterally with no erythema or effusion. Nares patent bilaterally. Gums are pink with no swelling, bleeding, no loose toothPharynx:Mucosa inflamed and red, beefy uvula,enlarged and red tonsils with exudate, petechiae on soft palate,tender and enlarged anterior cervical lymph nodesNeck:Supple. no masses, no carotid bruit noted. No limited ROM, positive for mild discomfort and tendernessLungs:clear to auscultation, no rales, no consolidation, no wheezing or stridor, no tachypnea, no use of accessory muscles, no pleuritic chest symptoms, no coughCardiovascular/Peripheral Vascular: RRR, no murmurs or gallops, peripheral pulses palpable, no edema, syncope, or palpitations,Gastrointestinal: Abdomen soft, nontender, nondistended. positive bowel sounds all 4 quadrants, no hepatosplenomegaly, positive for nausea, no vomiting, positive for poor appetiteMusculoskeletal:full range of motion all extremitiesSkin:no rashes, skin warm to touch,Diagnostic test results Rapid antigen detection test (RADT)- positiveThroat culture- positiveAssessmentPriority diagnosis
Group A streptococci pharyngitisis a bacterial infection caused by Group A β-hemolytic (GABHS) streptococcus. It is mostly found in children between the ages of 5-15 years old (Burnset al., 2017). It is characterized by a sudden onset of fever, severe sore throat and malaise, nausea, headache, with the absence of cough and upper respiratory tract symptoms (Dains et al., 2016). Its occurrence increases during winter or early spring (Burns et al., 2017). Physical exam reveals temperature greater than 101.5°F, tonsillopharyngeal exudate, petechiae on soft palate, swollen beefy red uvula, tender and enlarged anterior cervical lymph nodes (Burns et al., 2017). The diagnosis of group A streptococcal pharyngitis cannot be reliable based on signs and symptoms alone. Therefore, a rapid antigen detection test (RADT) and/or throat culture should be performed (Shulman et al., 2012). A positive rapid antigen detection test (RADT) or throat culture confirms the diagnosis of group A streptococcal pharyngitis (Burns et al., 2017).
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- Spring '18
- urinary tract infection, Burns, Upper respiratory tract infection, pediatric Primary care , Nurs 6541 Exam