Health assessment. Chief Complaint: coughing. Health, Medicine Essay

For my assessment

l need 3 Differential Diagnoses:

Diagnostic tests

Treatment

Initials, Danny. Age, 8years, Sex- male, Puerto Rican

Chief Complaint: coughing

HPI: Danny Rivera is an 8 year old Puerto Rican boy who presents today with her grandmother and complain of productive cough for 5 days.  No fever, emesis.  He states that he has been coughing at night and it disturbs his sleep.  He coughs clear slummy stuff and has a runny nose.

Location: chest

Onset: The last 5 days

Character:

Associated signs and symptoms: A running nose, right ear pain, sore throat

Current Medications: Daily Multivitamin, Reports mom gives him a spoonful of purple cough medicine

Allergies: No known allergies

Immunization:  No flu vaccine in the last 12 months.  His immunizations are up to date

Past Medical History: Pneumonia last year (treated at urgent care clinic).

Hospitalization: No prior hospitalization

Family History:

Mother: Type 2 Diabetes, Hypertension, Hypercholesterolemia, obesity, spinal stenosis

Father: smoker, asthma as child, hypertension, hypercholesterolemia

Maternal Grandmother: Type 2 Diabetes, Hypertension

Maternal Grandfather: smoker, eczema

Paternal grandmother: Died in a car accident at age 52 years old

Paternal grandfather: No known history

Social History: lives with mother and father but grandmother take care of him while parents work. Speaks primarily English at home but Spanish is used.  He is in 3^rd grade. He was out of school for 2 weeks due to pneumonia last year.

Lifestyle: Reports always feel safe at home and have a good family

Review of Systems:

GENERAL: The patient is alert even though he appears tired. While seen in the clinic, he coughs about every 5 minutes and the cough is dry. Denies fever, chills, night sweats

HEENT:  Eyes:  Denies vision or hearing problem. Patient sclera is normal. Reports right ear pain.  No discharge.  Pain is 3/10.  Reports runny nose and sore throat. No congestion of nose. Denies difficulty swallowing, headaches, dizziness, vertigo

CADIOVASCULAR: Denies chest pain, discomfort, chest tightness, palpitation

RESPIRATION: Denies shortness of breath, dyspnea. He states his breathing seems good even though he has a runny nose, he can still breathe ok. Cough presents every 5 minutes during the day and worse at night

GASTROINTESTINAL: Denies nausea, vomiting or diarrhea.  No abdominal pain, weight loss, loss of appetite  

GENITOURINARY:  Denies urinary urgency, frequency, hematuria, incontinence.

NEUROLOGICAL: Denies headache, dizziness, syncope, ataxia or numbness

MUSCULOSKELETAL:  Denies back pain, muscle pain, joint pain or stiffness.

HEMATOLOGIC:  Patient isn’t anemic and bleeding or visible bruises. 

ENDOCRINOLOGIC:  Denies polyuria or excessive sweating

OBJECTIVE

Vital signs

T. 37.2c

Pulse-100

RR-28

BP 120/76

Spo2 96%

Spirometer: FEVI: 3.15L, FVC3.9IL (FEV1/FVC) 80.5%

Physical Examination

General: Alert, well nourished, good hygiene.  Cough several times a minute.  No distress noted

HEAD: Normocephalic, no scalp lesions

EYES: Pupils equal, round, reactive to light and accommodation

EARS: Left tympanic membrane intact, dull, gray and normal land mark.  Right tympanic membrane bright red bulging

NOSE: Nare patent and clear mucus

THROAT: Clear

NECK: No lesions

SKIN:  No rashes or itches, masses, lesions excessive dryness noted; no dryness or flaking of scalp or hair.

HEART: Regular rate and rhythm, S1, S2 good no murmur

LUNGS: Clear to auscultation bilaterally. No wheezes, no crackles. Cough clear mucus.

CHEST:  Normal shape and expansion

ABDOMEN: Soft, nondistended. No masses.

3 Differential Diagnoses:

Diagnostic tests

Treatment