General Survey: Fatigued appearing young boy seated on nurs station bench. Appears stable
General Survey: Fatigued appearing young boy seated on nurs 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 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. A 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, FV 3.91L (FEV1/FVC: 80.5%)
Your Results Lab Pass (/assignment_attempts/6699430/lab_pass.pd
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Document: Vitals Document: Provider Notes
Student Documentation Model Documentation
Assessment
Differential diagnosis: 1. flu-like syndrome or cold 2. strep throat 3. Allergies 4. Allergic rhinitis
My differentials include cold, strep throat, rhinitis, allergies and asthma based on abnormal findings affecting the ears, upper respiratory tract and lymphatic region.