SAN BEDA UNIVERSITY

College of Medicine

MEDDIAG 20 (PHYSICAL DIAGNOSIS)

PEDIA CASE 1

PD Pedia: CARLA ELIZE DERAIN PD IM: Gian Carlo Escobedo

YL – 2A YL2-A

General Data
Betsy, a 5-year-old girl, is brought by her mother for evaluation of a sore throat.
Chief Complaint
Sore throat and fever
Reliability
Source: Mother; Reliability: 90%
History of Present Illness:
A night PTC, the patient started complaining of a sore throat characterized as sore and sractchy.
The sore throat is accompanied with ear ache and worsens when the patient swallows. The patient also
developed undocumented fever. Tylenol was given which brought down the temperature a little but patient
was still febrile. No consultation was done this time.
In the morning before the consult, the symptoms persisted and rashes on her chest area was
observed by the mother. The patient also vomited once which prompted the mother of the patient for a
consult.

Review of Systems
Constitutional symptoms
General: (+) Poor appetite (+) decrease in activity level (+) weakness
Cutaneous: (-) cyanosis (-) jaundice (-) flushing (-) pruritus (+) rash (-) skin discoloration
HEENT: (-) headache (-) eye redness (-) eye dryness (-) blurring of vision (-) ear discharge (-) ear
redness (-) tinitus (-) hearing loss (-) nose stuffiness and discharge (-) no nose redness and
swelling (-) epistaxis (+) dysphagia (+) hoarseness (+) mucosal redness (-) oral ulcers (-) lymph
node enlargement, pain and redness
Cardiovascular: (-) cyanosis (-) jaundice (-) flushing (-) chest pain (-) palpitations
Respiratory: (-) dyspnea (-) cough (-) wheezing
Gastrointestinal: (-) constipation (-) diarrhea (+) abdominal cramps
Genitourinary: (-) dysuria (-) hematuria
Nervous/Behavioral: (-) Change of behavior, (-) seizures, (-) convulsion
 Musculoskeletal: (+) weakness (-) history of trauma (-) limitation of motion
Endocrine: (-) polydipsia (-) polyphagia
Hematologic: (-) pallor (-) no bleeding

Past Personal History

A. Birth and Maternal History
 Born to a (age of the mother was not assessed) year old, G2P2 (2-0-0-2)
 Prenatal check-up: not assessed
 Medications: not assessed
o (-) Smoking, (-) Drinking alcoholic beverage
 Maternal Illness: Preeclampsia
 Screening tests: not assessed
 Delivered via Caesarean section due to preeclampsia at a hospital in their town
 Condition at Birth: Term, good cry, pinkish, active
 Birth weight: 7 lbs and 2 ounces
 NBS and results was not assessed
B. Feeding History
 Eat three healthy meals a day with a snack in the afternoon and 2% milk.
 Takes one chewable vitamin with fluoride a day
C. Developmental History
 No growth delay
 Normal developmental history
D. Past Illness
 (+) Ear infection, 1 month PTC treated with Batcrim
 (+) Allergy to penicillin
 (-) Asthma, TB, Congenital diseases
 (+) Hospitalization
 (-) Blood transfusion
 (-) Injuries caused by accidents

Immunization History
 DTaP - five doses
 IPV - four doses
 Hib - four doses
 HBV - three doses
 MMR - two doses
  Varicella - two doses
 Rotavirus - three doses
 PCV13 - four doses
 HepA - two doses

Family History
 Mother: Housewife, non-smoker, healthy
 Father: works with different gases, non-smoker, healthy
 Sibling: 15 months old, healthy
 (-) Diabetes, hypertension, respiratory diseases, cardiac diseases or cancer

Socioeconomic History
 Primary Caregiver: Mother
 Living with his mother, father and sibling
 Patient’s family owns a 2-storey house and 2 cars for the parents
 Sources of funds come from father’s construction income
 Source of water: Not assessed
 Goes to day care/ pre-school five days a week

Environment History
 (+) Frequent interaction with children in their town and school day care
 (-) History of recent travels
 (-) Environmental hazards

Physical Examination
General Survey: The patient is a quiet, fairly comfortable and cooperative 5-year-old girl.
Vital Signs and Anthropometrics

Z-SCORE Interpretation
Height: 106.7 cm
Weight: 18.1 kg LENGTH-FOR- -1 Normal

Blood Pressure: 85/60 mm Hg AGE

Heart Rate: 100 WEIGHT-FOR- 0 Normal

Temperature: 38.7 ° C (101.7 ° F) AGE

Respiration: 16 WEGHT-FOR- 0 Normal

Pulse: 100 LENGTH

O2 sat: 97% BMI-FOR-AGE +0.5 Normal

Rhythm: Regular
 HEENT: Patients head is symmetrical, no lesions or injury were noted with normal hair texture and
color.
Eyes are symmetric in size, shape, color and position. No scars, ertyhma, or growths noted on lid
or conjuctiva. Cornea is clear; pupil is round, equal and black. Conjunctiva is moist and without discharge.
The patient's nose is symmetric and without apparent deformity. There is no mucosal swelling with
minimal clear drainage.
Auricles of the ears are symmetric, normally placed, and without deformities; no area of tenderness
is noted. There is no visible drainage. No ear lobe creases are present. Upon otoscopy, patient's right ear
canal is clear; the drum is intact, but is markedly erythematous and injected. The drum is opaque, and the
malleus cannot be seen. No movement of the drum can be produced with insufflation. Left ears canal and
drum is normal.
Lips are moist without cracking or lesion. Tongue is moist, midline, and has a "strawberry tongue"
appearance. Limited visualization of the teeth shows all primary teeth present and in good repair. Limited
view of the palate shows it to be intact without lesion. The tonsils and posterior pharynx cannot adequately
be visualized by viewing alone.
There are no pre or post auricular nodes, nor any posterior cervical nodes. There are multiple
enlarged (0.5-1 cm), slightly tender anterior cervical nodes bilaterally. Both lobes of the thyroid are small,
smooth, nontender and without nodules.
Chest and Lungs: The chest is symmetric. Respiratory movements are quick and symmetric. No
retractions are present. Respiratory rate is regular, bradypneic at 16 breaths per minute, without use of
accessory muscles. A fine, scattered, erythematous maculopapular rash is visible over the anterior chest
wall.
Cardiovascular: no cyanosis, normal heart rate and rhythm at 100 bpm, hypotensive at 85/60 mm
Hg
Abdomen: The abdomen is symmetric, smooth without striae, and rashes. The bowel sounds are
normoactive. On percussion, tympanic sounds are heard.

Genitalia: Not assessed

Extremities: Not flaccid, rigid, nor spastic

Peripheral Vascular: full and equal pulses on all extremities

Back/Spine: Unremarkable

Musculoskeletal: Not assessed

Neurological: Awake, conscious, uncooperative. No noted seizures and tremors.

Salient Features:

SUBJECTIVE OBJECTIVE

 CC: Sore throat and fever  Temp: 38.7 ° C (101.7 ° F) (febrile)

 Age: 5 years old  (+) fine, scattered, erythematous
 (+) Dysphagia (+) vomiting (+) rash maculopapular rash on chest
 (-) Chills (-) flushing (-) headache  (+) Paplpable cervical lymph node
 (+) Frequent interaction with children in  (+) Strawberry tongue
their town and school day care  (+) Ear pain
 (+) Allergy to penicillin  (+) Eardrum is markedly erythematous
and injected opaque
 (-) Red creases in armpits, elbows and
knees: Pastias line

Differential Diagnosis:
DDX DDX MORE LIKELY LESS LIKELY
DESCRIPTION
INFECTION Streptococcal Infection of the (+) Fever of greater than (-) headache
pharyngitis back of the 38C (+) Strawberry tongue
throat including (+) Sore throat
the tonsils (+) Paplpable cervical
caused by lymph node
group A strepto (+) Vomiting
(+) Dysphagia
(+) Fine, scattered,
erythematous
maculopapular rash on
chest
(+) Ear pain
INFLAMMATION Otitis Media Group of (+) Ear pain (+) Strawberry tongue
inflammatory (+) Eardrum is markedly (+) Fine, scattered,
diseases of the erythematous and erythematous
middle ear. injected opaque maculopapular rash on
(+) Ear infection, 1 month chest
PTC treated with Batcrim
Risk factor: (+) Allergy
 Risk factor: Age: 5 years
old
(+) Exposure to group day
care
INFLAMMATION Tonsilitis Inflammation of (+) Fever of greater than (+) Strawberry tongue
the tonsils 38C (+) Fine, scattered,
(+) Sore throat erythematous
coarse rales and maculopapular rash on
occasional wheezing on chest
both lung fields
(+) Ear pain

Primary Working Impression: SCARLET FEVER

MORE LIKELY LESS LIKELY

(+) Strawberry tongue (-) Chills

(+) Fine, scattered, erythematous maculopapular (-) flushing
rash on chest
(+) Fever of greater than 38C
(+) Sore throat
(+) Paplpable cervical lymph node
(+) Vomiting
(+) Dysphagia
Risk factor: (+) Frequent interaction with children in
their town and school day care
Risk factor: Age: 5 years old