Pediatric diseases (Due 20 and 40 hours)
Edero2103
Pediatricdiagnosiscases.docxDiagnosis: Conjunctivitis
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Chief complaint: (State the patient's complaint in the first person) |
“I have itching in my right eye” |
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HPI: In no more paragraph, indicate the patient's situation include: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment:
Example: 8 days ago(O) my left eye (L) is itching (C), the itching has been progressive (D) and worsens with heat(AF), but the cold relieves the discomfort a little (RF), I took acetaminophen but it did not improve (T) |
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Immunization |
Indicate the last vaccination date applied according to age. Include Covid vaccine |
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ROS |
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Eyes: |
Reports Itching in right eye 8 days ago |
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OBJECTIVE Patient data must match age |
Age: 16 YO Weight 65kg BMI 21.5 Height 160cm Temp 97.7 F BP 120/61 Pulse 100 beats per min Resp 32 breaths per min |
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Eyes: Indicate the physical and clinical findings of the patient compatible with the pathology. It is not allowed to repeat the patient's complaint. All terminology must be medical and indicate clear symptoms of the indicated diagnosis. |
Right eye erythematous with mucopurulent discharge; edematous right eyelid; normal visual acuity; cornea clear bilaterally, and extraocular eye movements intact. No nystagmus was noted
Words without meanings are not allowed. Use only sentences |
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Pharmacological treatment: Include, dose, how often and for how long Minimum 2 drug per table |
Erythromycin 0.5% ointment applies BID in right eye for 5 days. Tylenol 500 mg, 1 tablet every 6-8 hours or Ibuprofen 200 mg, 200 mg liquid gel caps every 6-8 for pain or fever.
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Diagnosis 1 |
H65.11 ACUTE AND SUBACUTE ALLERGIC OTITIS MEDIA |
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Chief complaint: |
“XXXXXX” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Ear |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Ear |
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Pharmacological treatment: |
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Diagnosis 2 |
H10.13 ACUTE ATOPIC CONJUNCTIVITIS, BILATERAL |
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Chief complaint: |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Eyes |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Eyes |
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Pharmacological treatment: |
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Diagnosis 3 |
J21.9 ACUTE BRONCHIOLITIS, UNSPECIFIED |
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Chief complaint: |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Respiratory |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Respiratory |
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Pharmacological treatment: |
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Diagnosis 4 |
K29.00 ACUTE GASTRITIS WITHOUT BLEEDING |
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Chief complaint: |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Abdominal |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Abdominal |
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Pharmacological treatment: |
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Diagnosis 5 |
J01.00 ACUTE MAXILLARY SINUSITIS, UNSPECIFIED |
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Chief complaint: |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Respiratory |
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Mouth |
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Nose |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Respiratory |
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Mouth |
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Nose |
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Pharmacological treatment: |
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Diagnosis 6 |
J80 ACUTE RESPIRATORY DISTRESS SYNDROME |
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Chief complaint |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Respiratory |
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Pulmonary |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Respiratory |
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Pulmonary |
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Pharmacological treatment: |
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Diagnosis 7 |
H66.0 ACUTE SUPPURATIVE OTITIS MEDIA |
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Chief complaint |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Ear |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Ear |
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Pharmacological treatment: |
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Diagnosis 8 |
J30.81 ALLERGIC RHINITIS DUE TO ANIMAL (CAT) (DOG) HAIR AND DANDER |
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Chief complaint |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Skin |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Skin |
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Pharmacological treatment: |
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Diagnosis 9 |
Z91.011 ALLERGY TO MILK PRODUCTS |
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Chief complaint |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Skin |
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Gastrointestinal |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Skin |
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Gastrointestinal |
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Pharmacological treatment: |
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Diagnosis 10 |
D64.9 ANEMIA, UNSPECIFIED |
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Chief complaint |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Skin |
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Eyes |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Skin |
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Eyes |
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Pharmacological treatment: |
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Diagnosis 11 |
W54.0 BITTEN BY DOG |
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Chief complaint: |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Skin |
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Musculoskeletal |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Skin |
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Musculoskeletal |
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Pharmacological treatment: |
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Diagnosis 12 |
J40 BRONCHITIS, NOT SPECIFIED AS ACUTE OR CHRONIC |
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Chief complain |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Nose |
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Pulmonary |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Nose |
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Pulmonary |
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Pharmacological treatment: |
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Diagnosis 13 |
R01.1 CARDIAC MURMUR, UNSPECIFIED |
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Chief complaint |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Cardiology |
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Pulmonary |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Cardiology |
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Pulmonary |
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Pharmacological treatment: |
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Diagnosis 14 |
L03.01 CELLULITIS OF FINGER |
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Chief complaint |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Skin |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Skin |
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Pharmacological treatment: |
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Diagnosis 15 |
M54.2 CERVICALGIA |
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Chief complaint |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Musculoskeletal |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Musculoskeletal |
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Pharmacological treatment: |
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Diagnosis 16 |
A74.0 CHLAMYDIAL CONJUNCTIVITIS |
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Chief complaint |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Skin |
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Eyes |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Skin |
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Eyes |
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Pharmacological treatment: |
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Diagnosis 17 |
Q35.9 CLEFT PALATE, UNSPECIFIED |
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Chief complaint |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Mouth |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Mouth |
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Pharmacological treatment: |
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Diagnosis 18 |
R10.83 COLIC |
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Chief complaint |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Gastrointestinal |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Gastrointestinal |
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Pharmacological treatment: |
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Diagnosis 19 |
K59.0 CONSTIPATION |
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Chief complaint |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Gastrointestinal |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Gastrointestinal |
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Pharmacological treatment: |
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Diagnosis 20 |
J45.991 COUGH VARIANT ASTHMA |
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Chief complaint |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Pulmonary |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Pulmonary |
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Pharmacological treatment: |
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Diagnosis 21 |
E30.0 DELAYED PUBERTY |
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Chief complaint |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Genitourinary |
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Endocrine |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Genitourinary |
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Endocrine |
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Pharmacological treatment: |
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Diagnosis 22 |
R19.7 DIARRHEA, UNSPECIFIED |
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Chief complaint |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Gastrointestinal |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Gastrointestinal |
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Pharmacological treatment: |
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Diagnosis 23 |
J39.9 DISEASE OF UPPER RESPIRATORY TRACT, UNSPECIFIED |
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Chief complaint |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Pulmonary |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Pulmonary |
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Pharmacological treatment: |
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Diagnosis 24 |
R14.3 FLATULENCE |
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Chief complaint |
“ ” |
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HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment |
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Immunization |
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ROS |
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Gastrointestinal |
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OBJECTIVE
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Age: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per min Resp XX breaths per min |
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Gastrointestinal |
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Pharmacological treatment: |
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