Ange
Sinnott, Angela
27/05/2013
CHART NOTE
This 7-year-old Hispanic boy was seen today, for complaints of sore throat and dysphagia. He states, he cannot swallow but spits into a rag because of the pain. His mother, who accompanies him today, took his temperature last night with a mercury thermometer and states it was 103.6 degrees.
Examination today reveals a child who appears in moderate distress. His skin is hot, and temperature was documented in the office at 39 degrees Celsius. Weight today was 51-1/2 pounds. Exam of the throat reveals the tonsils to be hypertrophic and kissing in the midline. The uvula is somewhat deviated to the left. There is erythema of the tonsils bilaterally with a peritonsillar abscess present on the right. The soft palate is bulging somewhat. Nose: The nares are patent with some clear nasal discharge. Ears: There is slight erythema of the tympanic membranes bilaterally. There is a blue collar button tube present in the right tympanic membrane; no tube is present on the left. He apparently had bilateral myringotomies with insertion of collar button tubes about a year and a half ago. Neck: The neck is supple with no motion tenderness. There are shotty nodes present. Rapid strep was performed and was positive.
DIAGNOSES
1. Acute streptococcal pharyngitis.
2. Otitis media.
3. Lymphadenopathy.
PLAN
A throat culture was obtained. Checking the chart, this boy did have a positive culture about 4 months ago with heavy growth of group A beta hemolytic strep. Mother states he had several episodes like this when he lived in Missouri. A throat swab was done for C&S. He is allergic to Amoxicillin so will give a course of cephalexin. The mother requested a liquid, and cephalexin oral suspension 12.5 mg/kg 3 times daily was ordered, this should also help the otitis media. The mom asked about tonsillectomy, and we spent several minutes discussing the criteria for a tonsillectomy. She is to bring the patient in for a re-check on
27/05/2013
CHART NOTE
This 7-year-old Hispanic boy was seen today, for complaints of sore throat and dysphagia. He states, he cannot swallow but spits into a rag because of the pain. His mother, who accompanies him today, took his temperature last night with a mercury thermometer and states it was 103.6 degrees.
Examination today reveals a child who appears in moderate distress. His skin is hot, and temperature was documented in the office at 39 degrees Celsius. Weight today was 51-1/2 pounds. Exam of the throat reveals the tonsils to be hypertrophic and kissing in the midline. The uvula is somewhat deviated to the left. There is erythema of the tonsils bilaterally with a peritonsillar abscess present on the right. The soft palate is bulging somewhat. Nose: The nares are patent with some clear nasal discharge. Ears: There is slight erythema of the tympanic membranes bilaterally. There is a blue collar button tube present in the right tympanic membrane; no tube is present on the left. He apparently had bilateral myringotomies with insertion of collar button tubes about a year and a half ago. Neck: The neck is supple with no motion tenderness. There are shotty nodes present. Rapid strep was performed and was positive.
DIAGNOSES
1. Acute streptococcal pharyngitis.
2. Otitis media.
3. Lymphadenopathy.
PLAN
A throat culture was obtained. Checking the chart, this boy did have a positive culture about 4 months ago with heavy growth of group A beta hemolytic strep. Mother states he had several episodes like this when he lived in Missouri. A throat swab was done for C&S. He is allergic to Amoxicillin so will give a course of cephalexin. The mother requested a liquid, and cephalexin oral suspension 12.5 mg/kg 3 times daily was ordered, this should also help the otitis media. The mom asked about tonsillectomy, and we spent several minutes discussing the criteria for a tonsillectomy. She is to bring the patient in for a re-check on