WEEK 5 DCE

Week 5 - Focused Exam: Cough Danny Rivera

Subjective

8-year-old Latino male patient presents today with abuela (grandmother) for c/o cough the past 5 days, sore throat since yesterday along with right ear pain. denies fever, chills, HEENT: denies headache or dizziness, EYES: vision unremarkable, denies eye pain, drainage or redness. EARS: +pain- right ear- 3/10, denies drainage or hearing loss, NOSE: denies sinus pain, +clear thin nasal drainage, reports almost always has runny nose, worse since cough started. THROAT: sore, 2/10, reports started after cough.

ROS CHEST/LUNGS: coughing every couple minutes, "worse at night"-keeps him from falling asleep easily. describes cough as "gurgled and watery". reports "sometimes" coughing up "slimy, clear stuff", reports mom gave cough medicine this am, denies any aggravating factors for cough. denies chest pain with or without cough, denies trouble breathing with cough.+tired from cough at night, denies heat/cold intolerance, takes multivitamin, NKDA or environmental allergies, no surgeries, no hospitalizations, PN last year- treated at urgent care- missed 2 wks. of school, HX ear infections, childhood immunizations up to date, no flu vaccine this past year, multivitamin daily, lives with mom, dad, grandparents, primary language is English- some Spanish, +smoke exposure in the home.

Objective V/S: 120/76, HR 100, R 28, T 37.2c Spo2 96%. Noted pediatric male patient sitting upright on table, alert/oriented- answers questions appropriately, pleasant affect, dressed appropriately.

Exam HEENT: no abnormal findings to orbital area- no edema, erythema, sclera white, conjunctiva moist, pink and without erythema or drainage, NOSE: frontal and maxillary sinuses palpated- nontender, not palpable, nares passages pink, patent/intact, clear drainage noted, no wounds/sores, polyps or bleeding noted. EARS: right ear canal erythema, tympanic membrane erythema, cone of light at 5:00, no bulging, intact, no drainage, no obstruction. Left ear canal pink, tympanic membrane intact, pearly/gray, no drainage, no bulging, cone of light at 7:00. THROAT: oral mucosa moist/pink, tonsils +erythema- without edema, no exudate, posterior oropharynx with notable cobble stoning and erythema, no post-nasal drainage noted. NECK: symmetric, no visible abnormality noted, palpable cervical nodes to right lat.

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CHEST/LUNGS: supraclavicular and axillary lymph nodes not palpable, palpable equal fremitus bilat, no visible retractions or accessory musculature used during respiration, -Bronchophony, all areas resonant with percussion- no dullness, chest symmetrical, no lesions or rash noted. Lung sounds present, CTA AP/bilat, CARDIAC: RRR, no rubs, palpitations, clicks, gallops, or murmur noted, S1 and S2 audible.

ABD/GU/RECTAL, MUSKULOSKELETAL - deferred.

Assessment Differential Diagnoses 1)Upper Respiratory infection

2)Ear infection

3)Pneumonia

Lab- CBC, rapid strep test, Chest x-ray, sputum culture

Plan Based on labs/diagnostics- antibiotics versus symptomatic care. relieve cough, rhinorrhea, ear and throat pain. humidifier, Tylenol/Advil, cough suppressant/expectorant. return PRN for new or worsening sx's- n/v/d, febrile, increased malaise/fatigue.

Rest, eat regularly, hydrate with water, take medications as directed, continue with multivitamin- instruct caregiver to monitor to make sure patient only takes as directed.

Wash hands frequently, avoid smoke exposure, refer ENT for frequent rhinorrhea/past HX frequent ear infections eval.

This study source was downloaded by 100000822253261 from CourseHero.com on 03-31-2021 15:15:37 GMT -05:00

https://www.coursehero.com/file/54465579/Focus-SOAP-note-Documentationdocx/

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