Based on the case below, List up to 3 diagnoses that might explain this patient’s complaints. List the most likely Diagnosis / Leading Diagnosis first (Group A Beta-hemolytic Streptococcus (GABHS), followed by 2 other reasonable possibilities / Alternative Diagnosis ( Viral Pharyngitis, Common Cold/Rhino virus). based on the history findings and physical findings, explain the Diagnostic Plan (labs, imaging, etc.) and Treatment Plans (Rationale)
Althea is a generally healthy five-year-old girl with a two-day history of subjective fever, sore throat, headache, dry cough, mild abdominal pain, and decreased appetite. She has a school friend who is taking antibiotics for strep throat, and her father smokes. On exam she has a temperature of 101.6 F, red, enlarged tonsils with exudates, anterior cervical lymphadenopathy, palatal petechiae, and a red, fine papular rash involving the neck, face, and trunk. She had not had dysphagia.
The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:
Epidemiology and risk factors: Generally healthy 5-year-old girl, potential strep exposure, second-hand smoke exposure.
Key clinical findings about the present illness using qualifying adjectives and transformative language:
two-day history of sore throat with associated headache, dry cough, mild abdominal pain, and decreased appetite
school friend who is being treated for strep throat with antibiotics
red, enlarged tonsils with exudates
anterior cervical chain lymphadenopathy
red, fine papular rash involving the neck, face, and trunk.
lack of dysphagia
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