Presenting Complaint

Difficulty swallowing for three days.
Sore throat.
Fever and rash.

History of Presenting Complaint

Patient has had difficulty swallowing for three days with associated sore throat.
White spot noticed to the back of the throat.
Reports high fever and a rash on the back.
Feels a bit rough.
No cough, no breathing problems, no headaches, no dizziness.

Observations

Patient appears lethargic.
Temp 38.9
RR 22
O2 98%
HR 120

On Examination

Capillary refill time less than 2 seconds.
No skin mottling, no cyanosis.
Moving and falling is normal, active.
Chest is clear, heart sounds are normal.
Throat appears erythematous with tonsillar exudates bilaterally.
Central uvula, tongue normal.
Rash on chest, sandpaper like, rough, maculopapular rash.

Plan

Phenoxymethylpenicillin 250mg/5ml PO QDS for 7 days.
General practitioner to follow up.
Telephone consult arranged in 48 hours to review.

Safety Netting

Advised mum if patient develops worsening symptoms to contact 111 or 999.

Audit

Presenting Complaint

Difficulty swallowing for three days. [1]
Sore throat. [1]
Fever and rash. [2]

History of Presenting Complaint

Patient has had difficulty swallowing for three days with associated sore throat. [1]
White spot noticed to the back of the throat. [2]
Reports high fever and a rash on the back. [2]
Feels a bit rough. [3]
No cough, no breathing problems, no headaches, no dizziness. [3]

Observations

Patient appears lethargic. [4]
Temp 38.9 [4]
RR 22 [4]
O2 98% [4]
HR 120 [4]

On Examination

Capillary refill time less than 2 seconds. [4]
No skin mottling, no cyanosis. [5]
Moving and falling is normal, active. [5]
Chest is clear, heart sounds are normal. [5]
Throat appears erythematous with tonsillar exudates bilaterally. [6]
Central uvula, tongue normal. [6]
Rash on chest, sandpaper like, rough, maculopapular rash. [6]

Plan

Phenoxymethylpenicillin 250mg/5ml PO QDS for 7 days. [6][8]
General practitioner to follow up. [6]
Telephone consult arranged in 48 hours to review. [7]

Safety Netting

Advised mum if patient develops worsening symptoms to contact 111 or 999. [8]