William Byrd, RN, FNP Student 5/15/2013, 9:45 11 Y/O Hispanic Male Patient Subjective Chief Complaint: I have

a sore throat, complaint from mother: the child has a fever and sore throat History of Present Illness: This is an 11 year old Hispanic male child. He presents to the clinic today with complaints of a sore throat. The mother states that yesterday morning the child felt fine. At lunch yesterday, the child states that he started having a sore throat, but continued through the school day. The mother states that the child went to bed early last night not feeling well (headache/body ache). Mother states that the child felt like he had a fever, but did not actually take temperature. The child vomited once last night, but has not vomited since and does not complain of stomach pain at the present time. This morning, the child had a fever of 103.8 at 8AM. The mother gave the child Tylenol at that time and the child now has a temperature of 97.4. The child still is complaining of a sore throat. He is in a public school, so there are many possible sick contacts, but the family does not know of any specific exposure to illness. Rapid strep testing was done upon arrival to clinic with results negative for strep throat. Current Health Status Allergies: None known allergies Medications: None prescribed. Patient has taken one dose of Tylenol this morning at 8AM. Immunizations: Up to Date. Health Maintenance Practice: N/A Self Exam: N/A Nutrition: The child eats a healthy diet prepared by the parents. The child eats school lunches at school. Exercise: The child does not participate in any organized sports, but he does participate in PE at school and plays basketball with his friends at home. Relevant Past Medical History General Health: The patient appears to be in good general health without acute distress. Surgeries: None Blood Transfusions: None Hospitalizations: None

Serious Accidents/Injuries/Fractures: None Major Illness: None Limitations of ADLs: None Social History Home Living Conditions: Lives with mother and father in a single family home. The child is an only child. The child is in 6th grade at the local public school. They have no pets. Occupation: 6th grade student Economic Resources: Dependent on the parents resources. Private insurance. Military Record: N/A Religious Concerns: None, Catholic. Patients explanatory model: The mother thinks that the child has strep throat. Family History: Both parents alive without significant history. All grandparents alive without significant history except paternal grandmother has DM. ROS Relevant Systems General-Confirms fever, headache and myalgia yesterday. Denies weight loss, night sweats, rash, or other constitutional changes. Denies appetite change, yet states that he is eating less due to sore throat making eating painful. Eyes-Denies discharge or redness. No stated visual problems. ENT-Confirms sore throat. Denies runny nose, nose bleeds, coughing, sneezing. Denies congestion. CV-Denies SOB or observed difficulty breathing. GI-Confirms one episode of vomiting last night. Denies diarrhea or constipation, difficulty feeding, bloody stools. GU-Denies hematuria or painful urination. Musculoskeletal-Denies pain or stiffness. Skin-Denies rashes, lesions, open wounds. Neurological-No observed deficits. Objective

Temp: 97.4 oral, BP:118/80, P:72, RR: 20, Ht: 60, Wt: 99lbs, BMI 19.4 Physical Exam Constitutional-Appears well nourished. Child is well groomed and quietly sitting on the exam table. The child appears to be in no acute distress. Skin: Normal turgor without rashes or lesions. HEENT-Normocephalic. Conjuntiva non injected, EOM intact, PERRLA, Tympanic membranes gray with landmarks visible. Nasal passages patent with unremarkable membranes. Mouth has moist mucous membranes. There are numerous, closely grouped small blisters on the posterior pharynx. No exudate present. Lymph node-No lymphadenopathy. Thyroid-No thyromegaly. CV-RRR, S1S2. No abnormal sounds. Lungs-Unlabored breathing, symmetric expansion, clear breath sounds. Abdomen-Soft, nontender, nondistended. Normal bowel sounds. No masses palpable. The Pediatric Symptoms Checklist was administered in the clinic visit. The mother did the evaluation and the child scored a 5, well below the cutoff point for this age. There were no answers to which the mother replied often. The only sometimes answers were: spends more time alone, distracted easily, has trouble concentrating, teases others, blames others for his troubles. In discussing the responses, the mother states that the child is not suffering in his school work but that he does occasionally get distracted while working on tasks. She does not feel that this is an abnormal behavior for the child. Since his school work is not suffering, she is not concerned about this at this time. She states that the teasing and blaming is only amongst his friends and extended family members (for example blaming cousin when they both were doing something bad). She states that the child will playfully tease these people, but not maliciously. The mother states that the time he spends alone is not concerning at this time because she feels that her and the father still have open communication with the child. Assessment Herpangina infection-The child has a fairly typical presentation according to Papadakis and McPhee (2013). There was a sudden onset, high fever of 103.8, and vomiting. The child also had a headache and general myalgia on the previous day. The blisters on the back of the pharynx are also consistent with the diagnosis of Herpangina. Differential Diagnoses

Strep throat-This was quickly ruled out due to the negative rapid strep test. Lack of exudate, presence of more than just erythema, no lymphadenopathy were also used to rule out Strep throat (Papadakis & McPhee, 2013) Pharyngitis due to the post nasal drip of Allergic Rhinitis-This was ruled out due to the lack of symptoms of allergic rhinitis. There was no coughing, sneezing, itchy/watery eyes. There was also no post nasal drip present (Papadakis & McPhee, 2013).

Plan The treatment plan for this patient is symptomatic relief (Papadakis & McPhee, 2013). Pharmacotherepeutics Acetaminophen or ibuprofen for fever control as needed. Prescribed magic mouthwash for sore throat. This is a mixture of 30ml Lidocaine, 60ml Benadryl, and 60ml Maalox. The directions are to swish and spit 10ml every 3-4 hours PRN for sore throat. Advised patient against using rinse before meals as the medication can cause loss of gag reflex and lead to choking. Diagnostic tests-Rapid strep test was negative Patient education-Advised that it was a viral infection that would resolve with time. Advised that cool foods may be easier to eat at this time. Avoid hot foods. Discussed safe use of magic mouthwash to prevent choking risks. Discussed with mother signs/symptoms of ADHD based on her noticing the child gets distracted on occasion so that she may be more aware of changes should they occur. No referral needed.

Rationale-This is a fairly classic presentation of herpangina according to Papadakis and McPhee (2013). The only required treatment is symptomatic treatment. I could find no specific reference to the use of magic mouthwash. I found that there are numerous combinations that can be used in the formulation of the mouthwash. I could find no factual evidence that the mouthwash actually works for controlling the pain associated with the sore throat.

References Papadakis, M. & McPhee, S. (2013). Current Medical Diagnosis & Treatment:2013. New York: McGraw Hill Medical.