Subjective
Chief Complaint (CC): “High fever, decreased appetite, sore throat.”
History of Present Illness (HPI): A 4-year-old girl was brought to the office by her father with
symptoms of high fever, decreased appetite, and sore throat for the past 3 days. The patient's
father mentioned that she recently started attending pre-school a few weeks ago and is worried
that she may have contracted the pathogen from school. The patient’s father reports that he has
been lowering the fever using an over-the-counter Children’s Motrin suspension.
Current Medications: Children’s Motrin suspension.
Allergies: No known allergies.
Social History: Patient has recently started attending preschool.
Review of Systems:
General: Reported fever, fatigue, and decreased appetite. No weight changes reported.
Ear, Nose, and Throat: Sore throat reported. No nasal congestion or otalgia reported.
Gastrointestinal: Decreased appetite reported. No report of nausea, vomiting, or diarrhea.
Objective
General: The patient appears tired and irritable.
Vital Signs: T: 38.5 degrees Celsius, BP: 95/ 67, SpO2: 99% on RA, RR: 21 breaths per min.
Cardiovascular: Normal rate and rhythm. S1 & S2 normal.
Respiratory: Clear breath sounds. No respiratory distress.
ENT: Sore throat with mild redness and slight enlargement of tonsils. No nasal discharge, no ear
tenderness observed on palpation.
Abdomen: Soft, non-tender. Bowel sounds x4.
Neurological: Normal gait. Cranial nerves intact. No nuchal rigidity.
Assessment
Diagnosis: Bacterial pharyngitis.
Plan
Pharmacological Treatment:
Amoxicillin suspension: 500 mg twice daily for 10 days
Motrin suspension 7.5 mL every 4 hours for fever as needed.
Non-Pharmacological Treatment:
Use salt gargles for irritated throat as needed.
Encourage fluids and rest.
