History

Full Name: A.E.

Sex: Female

Age: 10 years

Date: June 5, 2024

Location: Dr. Hurwitz Pediatrics

Source of Information: Self and Mom

Reliability: Reliable

Source of referral: Self

Mode of transportation: Car

Chief Complaint: As per mom, “she has fever” x9 days.

HPI:

A.E. is a 10 year old female with no significant past medical history who presents to the pediatric outpatient office today with concerns of fever for the past 9 days. This morning the fever was 101.5 temporally, with a max temp of 103.5 over the past 9 days. Fever does resolve with Tylenol. The fever happens at any time throughout the day, with no preference to any specific time of day. Pt was seen in another office 8 days ago due to the fever and was diagnosed with strep. She was prescribed amoxicillin. However, despite the amoxicillin, the fever persisted for 4 more days. Mom says the pt took the medication as prescribed and was compliant with the treatment. She returned to the same doctor who switched her medication to augmentin. The fever continued to persist and 2 days later, pt was sent for a chest x-ray. Results were concerning for a R upper lobe pneumonia. Augmentin was continued, however fever is still present. At the time of the chest x-ray, CBC was WNL with a mildly elevated ESR (29) and CRP (51.8). Pt also has a cough. The cough is worse at night and is persistent. Pt additionally has a loss of appetite and is weak/tired making her miss school and participating in her usual activities. Mom decided to bring pt to our office for a second opinion.

Denies sore throat, headache, vomiting, diarrhea, hemoptysis, weight loss, night sweats. 

Past Medical History: 

• Present concern: Fever
• Past medical illnesses: None 
• Childhood illnesses: None 
• Immunizations: Up to date
• Past Surgical History: None
• Medications: Augmentin
• Allergies: None
• Family history: Not on file

Social History

• A.E. is in fourth grade in an all girls private school. She lives in a private home with her parents and siblings and no pets. There is no smoking, alcohol or illicit drug use in the house. She denies recent travel. Pt sleeps about 10 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. 

Review of Systems:

• General: Admits to fever, loss of appetite and fatigue. Denies chills, night sweats, weight loss/gain.
• Skin, hair, nails: Denies bruising, discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
• HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, congestion, sore throat.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM
• Pulmonary: Admits to cough. Denies dyspnea, wheezing, cyanosis, hemoptysis.
• Cardiovascular: Denies cyanosis, syncope, edema.
• 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.
• Nervous system: Denies seizures, headache, loss of consciousness, head trauma, loss of strength.
• 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, though she does appear weak and lethargic.

Vitals:

• HR: 100 beats per minute, regular rate, rhythm and amplitude  
• RR: 18 regular rate and rhythm, unlabored
• T: not done 
• BP: not done
• Weight: 70 lb 
• Height: 55 in

Skin: 

• Warm and moist, good turgor. Nonicteric, no scars, cyanosis, erythema or lacerations 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. Mild clear 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 with no spontaneous bleeding. Good dentition. No obvious dental caries noted. Tongue pink and well papillated, no masses or abnormalities. Oropharynx well hydrated with no injection, exudate, masses, lesions or foreign bodies. Tonsils present with no injection or 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:

• Mycoplasma pneumonia
• Viral respiratory infection
• Tuberculosis
• Kawasaki

Assessment:

• 10 year old female with no PMHx presents with fever for the past 9 days. Pt was started on amoxicillin and then switched to augmentin, with no resolution of the fever. Vital signs and all aspects of the physical exam are within normal limits. Presentation is consistent with atypical pneumonia, such as mycoplasma pneumonia. 

Plan:

• Obtain labs
  • CBC, CMP, ESR, CRP
  • Mycoplasma pneumonia antibodies
• Switch from augmentin to azithromycin
  • ~320 mg once on day one, followed by ~160 mg once daily on days 2-5
  • Strength of 200 mg/5 mL: ~10 mL (2 tsp) on day one, ~4 mL on once on days 2-5
  • Dosing is 10 mg/kg once on day 1 followed by 5 mg/kg/dose once daily on days 2 to 5
• Symptomatic treatment
  • Tylenol as needed
  • Maintain hydration
• Return in 48 hours to assess clinical response. Return sooner if fever worsens or if pt appears to be in distress.
• Educate regarding disease course and contagion- hand hygiene, slow course of recovery, introducing activity based on tolerability.