reported. No food allergies reported.
OBJECTIVE
General: Male presenting in no acute distress, well hydrated, conversational and appropriate with provider.
Vital signs: Height: 68 in; weight: 135 lbs; BMI: 20.5; BP: 116/70; HR: 75; RR: 16.
Skin: Skin is clear with no rashes noted. Small scar is noted at right lower abdominal quadrant s/p appendectomy. Skin is warm and dry.
HEENT: On examination, right eye is mildly injected, with thick, yellow discharge draining from inner canthus. Dried, yellow crusting is noted across lower lid. Upon cleansing the canthus, discharge reappears spontaneously throughout duration of exam. Pupils are equal and round, reactive to light, with accommodation showing normal pupillary reflex. Visual acuity is 20/20 on Snellen test with corrective lenses. Red reflex is noted and optic discs are without hemorrhage.
Head is normocephalic and atraumatic. Tympanic membranes are clear, intact, with landmarks and cone of light visualized, bilaterally. Nasal turbinates are pale, swollen, and with mild clear discharge. Nasal septum is vertically aligned with no report of pain or discomfort upon palpation of frontal and maxillary sinuses. Oral pharynx is clear with no erythema noted. Tonsils +2 of 4 with no exudate or erythema. Posterior pharynx has minimal post nasal drainage and mild cobbling.
Neck: Supple with full range of motion in all directions. No cervical lymphadenopathy.
Cardiovascular: Regular rate and rhythm. S1/S2 auscultated with no murmur, clicks, rubs, gallops. Equal +2 carotid and radial pulse bilaterally.
Respiratory: Clear to auscultation. No wheezes, rhonchi, rales noted. Good air exchange.
Abdomen: Soft, nontender, nondistended, normal active bowel sounds in all 4 quadrants.
Genitourinary: Deferred.
Neurologic: Alert and oriented. Cranial nerves grossly intact. Good eye contact. Gait normal. Uvula rises midline and symmetrically.
CRITICAL THINKING
1 What are the top three differential diagnoses in this case and why?
2 What are the diagnostic tests required in this case and why?
3 What is the plan of treatment?
4 Are there any standardized guidelines that should be used to treat this case? If so, what are they?
5 What are the plans for follow‐up care and referral?
6 Are there any special examination and or treatment considerations that may affect this case?
Case 4.4 Sore Throat
By Mikki Meadows‐Oliver, PhD, RN, FAAN
SUBJECTIVE
Eight‐year‐old Suzanna presents to the office with a complaint of a sore throat for 2 days. She is accompanied by her mother, Mikayla. Suzanna has had an intermittent fever and her maximum temperature at home was 101°F (oral). Suzanna complains that she has pain when she swallows. She also complains of a headache. Both the throat pain and headache are relieved slightly with the use of over‐the‐counter pain relievers. Suzanna has had no vomiting or diarrhea. She has had no runny nose or cough. She denies drooling or difficulty breathing.
Diet: Suzanna’s nutrition history reveals that she normally has a balanced diet with enough dairy, protein, fruits, and vegetables. Her appetite has decreased over the past 2 days since the throat pain began.
Elimination: She is voiding well with no complaints of dysuria.
Sleep: Suzanna usually sleeps approximately 9 hours at night. She usually has no problems falling or staying asleep but since the throat pain has started, her sleep has been interrupted.
Past medical history: Suzanna was born via vaginal delivery at 38 weeks’ gestation. Since being discharged at 2 days of age, she has had no hospitalizations. Suzanna had an emergency department visit at 4 years of age for a broken clavicle that she sustained after falling from the jungle gym at preschool. She has had no injuries or illnesses since that time.
Family history: Suzanna’s mother (28 years old) has a history of hyperthyroidism. Her father (30 years old) is healthy and has no history of chronic medical conditions. Her maternal grandmother (56 years old) has emphysema. Her maternal grandfather (57 years old) has a history of asthma. Suzanna’s paternal grandfather (58 years old) has a history of hypertension. Her paternal grandmother (53 years old) has multiple sclerosis.
Social history: Suzanna currently attends elementary school. She is in the third grade and is doing well, according to Mikayla. Suzanna lives at home with her mother, who works as an office manager, and her father, Joe, who is a professional carpenter. The family has a pet fish. Suzanna attends an after‐school program.
Medications: Suzanna is currently taking no prescription or herbal medications. She has been taking over‐the‐counter pain relievers/antipyretics to relieve symptoms associated with her throat pain.
Allergies: Suzanna has no known allergies to food, medications, or the environment. She is up to date on required immunizations.
OBJECTIVE
General: Alert, quiet, and cooperative; appears well hydrated and well nourished.
Vital signs: Weight in the office today is 36 kg; temperature is slightly elevated at 38.4°C (oral).
Skin: Clear of lesions and warm to touch. There was no cyanosis of her skin, lips, or nails. There was no diaphoresis noted; skin with elastic recoil.
HEENT: Normocephalic; red reflexes are present bilaterally; and pupils are equal, round, and reactive to light. There is no ocular discharge noted. External ear reveals that the pinnae are normal and that there is no tenderness to touch on the external ear. On otoscopic examination, both tympanic membranes are gray, in normal position, with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic membranes. Both nostrils are patent. There is no nasal discharge and no nasal flaring. Samantha’s mucous membranes are noted to be moist when examining her oropharynx. Both tonsils are erythematous and inflamed. There are exudates present bilaterally, as well as palatal petechiae.
Neck: Supple and able to move in all directions without resistance; tender anterior cervical nodes present on both sides of the neck; no erythema of the nodes.
Respiratory: Respiratory rate was 28 breaths per minute, and her lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted.
Cardiac: Heart rate was 112 beats per minute with a regular rhythm. There is no murmur noted upon auscultation.
