History

Full Name: L.P.

Sex: Female

Age: 5 years

Date: June 2, 2024

Location: Dr. Hurwitz Pediatrics

Source of Information: Mom

Reliability: Reliable

Source of referral: Self

Mode of transportation: Car

CC:

As per mom, “pt’s ears hurt” x1 days

HPI:

L.P. is a 5 year old female with no PMHx that presents to the outpatient pediatric office with her mom. Mom states that the pt has erythema infectiosum but is no longer contagious because she developed the rash, indicating the end of her contagion, 2 days ago. Fifth disease was going around in her class and last week she developed a cough, congestion, fever and then the rash appeared. Mom says the rash began on pt’s trunk and arms and then appeared on her cheeks. Pt has been feeling fine since the rash appeared and has not complained of itchiness or pain by the rash. Additionally, her cough and congestion resolved. However, yesterday pt began to complain of ear pain and developed a fever again. Pt is unable to characterize the pain any further, but does say it is worse when she swallows. Mother noticed clear drainage from the pt’s R ear. Fever is about 100.8 tympanically, as per mom. Pt was given motrin about an hour ago.

Denies cough, congestion, known exposure to illnesses other than erythema infectiosum, trauma to the ear and recent antibiotic use. 

Past Medical History: 

• Present concern: Ear pain
• Past medical illnesses: None 
• Childhood illnesses: Erythema infectiosum  
• Immunizations: Up to date
• Past Surgical History: None
• Medications: None
• Allergies: None
• Family history: Mother and father alive and well. She has 4 older siblings all alive and well. There is no known significant family history.

Developmental milestones

• Talks well, using long meaningful sentences
• Tells simple stories and nursery rhymes
• Creates imaginary stories, fantasies and/or situations
• Skips or hops on one foot 4-5 times
• Runs on tiptoes
• Stacks 10 or more blocks
• Uses crayons or scissors well
• Draws a person with a head, body, arms and legs
• Dresses self without supervision

Social History

• L.P. is in pre-1A and lives in a private house with her parents and four older siblings. They have no pets. Noone in the home smokes or drinks alcohol. She denies recent travel. Pt sleeps about 12 hours each night and feels rested. She does not participate in any extracurricular activities. Her diet is balanced and consists of chicken, meat, fruits, vegetables and healthy carbs. She adheres to a kosher diet. 

Review of Systems:

• General: Admits to fever. Denies fatigue, chills, night sweats, weight loss/gain, changes in appetite.
• Skin, hair, nails: Admits to rash. Denies discolorations, moles, bruising, changes in hair distribution or texture, pruritus.
• HEENT: Admits to ear pain and drainage. Denies head trauma, hearing loss, epistaxis, congestion, sore throat.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM
• Pulmonary: Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
• Cardiovascular: Denies syncope, edema, cyanosis.
• Gastrointestinal: Denies abdominal pain, nausea, vomiting, jaundice, diarrhea, constipation.
• Genitourinary: Denies dysuria, urinary frequency, nocturia, urgency.
• Musculoskeletal: Denies back pain, muscle pain, joint pain and joint swelling.
• Hematologic: Denies anemia, easy bleeding/bruising and lymph node enlargement

Physical

General:

• The patient appears her stated age, well developed, well nourished and in no apparent distress.

Vitals:

• HR: 95 beats per minute, regular rate, rhythm and amplitude  
• RR: 21 regular rate and rhythm, unlabored
• T: 99.1 F, temporally
• BP: not taken
• Weight: 40 lb (19 kg)
• Height: 42 in

Skin:

• Reticular, pink rash on abdomen and bilateral upper extremities. Red circular rash on R cheek, L cheek faded pink circular rash. Warm and moist, good turgor. Nonicteric, no scars noted.

Ears:

• Symmetrical and appropriate in size, in line with the eyes. No erythema, tenderness, swelling on external ears. No discharge, foreign bodies, inflammation in external auditory canals AU. TMs pearly gray/intact with light reflex in good position AU.

Eyes:

• Symmetric, in normal position OU. No eyelid edema or discharge from eyes. Sclera white, cornea clear, conjunctiva pink.

Nose:

• Symmetrical. No masses, lesions, deformities, trauma. No discharge visualized. Nares patent bilaterally. Nasal mucosa is pink and well hydrated. Septum midline without lesions, deformities, injection, or perforation. No foreign bodies.

Throat:

• Gingiva is pink and moist throughout. Good dentition. No obvious dental caries noted. Tongue pink and well papillated, no masses or abnormalities. Oropharynx well hydrated with no exudate, masses, lesions or foreign bodies. Tonsils present, moderately enlarged with moderate injection and no exudate. Uvula midline, pink with no edema or lesions.

Neck:

• Trachea midline. No masses, lesions, scars, pulsations. Supple and non-tender to palpation. Thyroid non-tender to palpation. No masses or thyromegaly noted.

Lymph nodes:

• No cervical lymph nodes.

Cardiac:

• Regular rate and rhythm. S1 and S2 are distinct with no murmurs or rubs. No S3 or S4. Radial pulses 2+.

Lungs:

• Symmetrical, no deformities, no trauma. Respirations even and unlabored, no use of accessory muscles, stridor or wheezing noted. Non-tender to palpation throughout. Clear to auscultation bilaterally. No adventitious sounds.

Abdomen:

• Abdomen flat and symmetric with no scars, striae or pulsations noted. No distention, soft, without tenderness. No rebound tenderness, guarding, or rigidity. No hepatosplenomegaly to palpation. No masses appreciated.

Neurologic:

• Patient is awake and alert.

Differential Diagnosis:

• Strep pharyngitis
  • The pt recently had a viral infection with upper respiratory symptoms, which makes her more susceptible to a superimposed bacterial infection. Additionally, the oropharynx is in close proximity with the eustachian tube which may be causing the ear pain. Strep also typically presents with fever which this pt has. Additionally, on exam the pt has enlarged and erythematous tonsils, indicating there is possibly an infection there.
• Eustachian tube dysfunction due to recent upper respiratory infection
  • Pt recently had symptoms of a URI including cough and congestion. This can cause the eustachian tube to drain improperly and thus fluid to build up. This may cause ear pain. However, the ear exam was benign which makes this less likely.
• Acute otitis media with TM rupture
  • AOM is common in children, especially after URI. This would be consistent with the pt’s complaints of ear pain and clear drainage from the ear. However, on exam in the office the ear exam was completely benign with no erythema or bulging/rupture of the TM. This makes the diagnosis way less likely.  

Assessment:

• 5 year old female recovering from erythema infectiosum presents with ear pain and new onset of fever. On exam, reticular rash of trunk and extremities were noted along with one red circular rash on the R cheek with a fading pink rash on the L cheek. Pt’s tonsils were enlarged and erythematous as well. Presentation is suggestive of a bacterial strep pharyngitis superimposed on erythema infectiosum. 

Labs:

• Rapid antigen detection test for strep: positive
• Overnight strep culture: pending

Plan:

• 6 mL (475 mg) of Amoxicillin 400 mg/5 mL Q12H (BID) x10 days
• Tylenol/motrin PRN
• Maintain fluid status
• Return to retest after completing the course of antibiotics
• Return sooner (4 days) if worsening pain or fever
• Educate regarding hygiene (ex. changing toothbrush, hand hygiene and close contact)