Cardiovascular: Denies chest pain or chest discomfort
Objective
Mr. Rivera is pleasant and cooperative fatgued appearing young boy seated upright on the examination table. He is in no acute distress. He is alert. His speech is clear and coherent. He maintains eye contact throught the interview and examination. He offers information freely and without contradiction.
HEENT: scleara white, conjuctiva moist and pink bilaterally. Rhinorrhea with clear mucus, nasal mucosa is boggy bilaterally. Right tympanic membrane is erythematous with inflammation. Right cervical lymph node is enlarged with noted tenderness. oral mucosa mosit and pink. Tonsils 2+ with erythema and inflammation. Posterior pharynx is erythematous with cobblestoning. Fine bumps noted on tongue.
Vital signs Blood pressure 120/76 O2 saturation: 96% on room air Pulse 100 Respiratory rate: 28 Temperature; 37.2
Cardiovascular: S1, S2, no murmurs, gallops or rubs. Mild tachycardia
Respiratory: Chest is symmetrical with respirations. Increased respiratory rate. Audible coarse crackles in upper airway; bronchovesicular bilaterally, clears with cough. Negative bronchophony. Chest wall resonant to percussion. Expected fremitus, equal bilaterally. Spirometry: FEV1:3.15L, FVC 3.91L( FEV1/FVC: 80.5%)
• General Survey: Fatigued appearing young boy seated on nursing station bench. Appears stable.
• HEENT: Mucus membranes are moist, clear nasal discharge. Redness, cobblestoning in the back of throat. Eyes are dull in appearance, pink conjunctiva. Right Tympanic membrane is red and inflamed. Right cervical lymph node enlarged with reported tenderness.
• Cardiovascular: S1, S2, no murmurs, gallops or rubs.
• Respiratory: Respiratory rate increased, but no acute distress. Able to speak in full sentences. Breath sounds clear to auscultation. Negative bronchophony. Chest wall resonant to percussion. Expected fremitus, equal bilaterally. Spirometry: FEV1: 3.15 L, FVC 3.91L (FEV1/FVC: 80.5%)
Assessment
My differentials include acute viral rhinopharyngitis. strep throat, allergic rhinitis, acute otitis media, allergies and asthma
My differentials include cold, strep throat, rhinitis, allergies and asthma based on abnormal findings affecting the ears, upper respiratory tract and lymphatic region.
Plan
Danny will receive a strep throat culture to rule out strep throat.
10 day dose of antibiotics for treatment of acute otitis media.
Refer for allergy tesing and pulmonary function test.
Encourage Danny to increase intake of water and other fluids and educate on frequent handwashing.
Recommend antitussive treatment at night to help with his sleep.
Danny should be referred for an allergy test to rule out allergies as well as a lung function test to rule out asthma. He should receive a strep culture to rule out strep throat. I recommend antitussive treatment at night to help with his sleep in addition to bed rest.
Comments
Rebecca Hall (14 Oct 2019, 10:17 AM CDT): Great interview, very thorough and flowed well. Documentation-you did a great job on your documentation-only comment I have is to include right and left on the exam-document negative findings for left ear and neck as well as pertinent negatives for all systems examined-I know Shadow does not do this but I want you to. include supporting positive or negatives for your differential diagnoses If you have not done so I highly recommend you view the recording of the soap documentation conference. There is much information on accurate and appropriate soap
https://www.coursehero.com/file/50185069/Cough-Shadow-Health-Documentationpdf/
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11/11/19, 3:44 PMFocused Exam: Cough | Completed | Shadow Health
Page 3 of 3https://app.shadowhealth.com/assignment_attempts/5468949
documentation and I believe this will help you with you the flow of your interviews and your documentation so you do not miss important items.
© Shadow Health 2012 – 2019®
https://www.coursehero.com/file/50185069/Cough-Shadow-Health-Documentationpdf/
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