Dani Rivera Pediatric Cough Soap Note Paper

Name: Dani Rivera

Section:

Week 5               

Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

SUBJECTIVE DATA

Chief Complaint (CC): `this cough is making me sick

History of Present Illness (HPI):

R, an 8-year-old male comes to the clinic accompanied by the mother. He complains of coughing in the past 6 weeks, sudden onset but has progressively been worsening over the last two weeks. There is no history of choking before the symptoms. A productive cough, yellow sputum and stained, worst at night, early in the morning and after exercise. He also experiences occasional shortness of breath. There is associated fever, night sweats, mild headache, mild weight loss, chest pain, and fatigue. Chest pain is graded at 4/10 and worse while coughing and relieved by taking pain killers.

Dani Rivera Pediatric Cough Soap Note Paper

He reports temporary relief on using antitussives and taking warm water. He was diagnosed with asthma at 3 years and has been admitted twice for pneumonia at 5 and 6 years. He has been using an albuterol inhaler to relieve asthmatic symptoms. He spends a lot of time with his grandfather who was diagnosed with pulmonary Tuberculosis 3 months ago. The father and grandfather are both smokers, making him at risk of being exposed to second-hand smoke. Mother had asthma in childhood and is allergic to pollen. He has a cat as his pet and spends the most time with it. He denies visual changes, ear pain, hoarseness of voice, and vomiting or nausea. Eating or lying flat does not worsen his symptoms.

Medications:

Albuterol inhaler PRN for asthma attack

Paracetamol 500mg three times a day for pain control

Antitussive PRN for cough

Allergies:

No known food allergy noted

Allergic to pollen grains, no allergy to pets

Past Medical History (PMH):

Diagnosed with asthma at 3 years

Treated for pneumonia at 5 and 6 years.

Two previous admissions

No history of chronic disease.

Past Surgical History (PSH):

No history of surgical history

No history of blood transfusion

Sexual/Reproductive History:

Born and raised as a male child

Identifies himself as being male and identifies his younger sister as being female.

Personal/Social History:

He is in the 2nd grade, always jovial, and enjoys the company of other children in school. He is always at the top of his class and loves mathematics. He plays football with his friends but is occasionally limited by the distressing symptoms that arise. He lives with his younger sister, mother, father, and paternal grandparents. He enjoys living with his family and loves their home. His grandfather and father smoke tobacco, drink alcohol, and the father becomes chaotic at times. When sick, he is forced to miss school but will always go to school once he feels better. Dani Rivera Pediatric Cough Soap Note Paper

Diet; fried eggs, cereals, tea for breakfast. Sandwich, potatoes, and fruits for lunch. Smoked fish and ugali for supper. Occasionally takes chocolate when sick.

Exercise; plays football occasionally, plays other outdoor games with friends.

Immunization History:

MMR- not received any dose since given at 18 months

Influenza- not given for the last 24 months

HPV- completed 2 doses at 6

Pneumococcal- 2 doses at 18 months

Hep A- completed at 24 months

Tetanus, diphtheria, and whooping cough completed 3 doses at 24 months.

Polio- competed 3 doses at 5 years

Significant Family History:

Paternal grandfather-age 72 years. TB, COPD, Hypertension, and smokes a cigarette

Paternal grandmother- age 65 years. Hypertension, asthma, type 2 diabetes

Maternal grandfather- 68 years, hypertension, obesity

Father- 35 years. Hypertension, obesity, smoke cigarette, and drink alcohol

Mother- 33 years. Asthma, obesity, hypertension

Sister; 5 years old. Asthmatic

Review of Systems:

General: reports loss of appetite and sleep disturbances. Denies chills nausea and vomiting.

HEENT:

Head- mild headache. Denies dizziness.

Eye – denies eye pain or visual changes.

Ear – denies pain, ear discharge, or reduced hearing.

Neck – denies pain, swelling, or difficulties in moving neck.

Throat – denies sore throat, difficulty in swallowing.

Respiratory: reports chest pain and shortness of breath. Denies difficulty in breathing.

Cardiovascular/Peripheral Vascular: complaints of shortness of breath and chest pain. Denies palpitations or murmur.

           

Psychiatric: no delusions, or disorientation reported

Neurological: denies weakness or disorientation

Lymphatics:  reports swelling under the armpits, no pain

Vaccination – childhood vaccinations are up to date.  Influenza and MMR not up to date.

           

OBJECTIVE DATA:

Physical Exam:

Vital signs:  Height 48 inches. Weight 53.0 lbs. Temperature 38.1, and BMI 16.7 and Pulse oximetry 94%

General: Young, well male sitting comfortably on the chair, sick looking, not in respiratory distress, maintains eye contact, and occasionally uses mouth for breathing and shows attachment to the environment.

HEENT: Head-normocephalic, poorly distributed thinned hair. Eye- no eye discharge, visual acuity is at 6/6, no conjunctival reddening, no jaundice, no conjunctival pallor.

Ear- no ear discharge or tenderness. Rhines test is positive AC> BC. Otoscopy shows a tympanic membrane that is intact without perforation, and is translucent, gray, and not retracted.

Nose- nasal septum present, nasal ridge without nasal polyps. Non tender maxillary sinus

Neck- nonpalpable thyroid gland. Bilateral cervical and axillary nodes enlargement. Submental nodes are enlarged and tender. Pre auricular, post auricular, supraclavicular, occipital nodes are non-palpable

Throat- pink oral mucosa, no swelling, the uvula is centrally placed. Good oral hygiene and missing maxillary lateral incisors.

Respiratory: inspection- chest moving with respiration, no deformity or therapeutic marks. Uses abdominal muscles for breathing, no nasal flaring. Respiratory rate of 33 b/min. Palpation- tenderness on touch, trachea centrally located. Vocal and tactile fremitus elicited. Auscultation- expiratory wheeze, reduced breath sounds. Percussion- hyper resonance.

 Cardiology: apex beat present at 5th intercostal space midclavicular line, regular rate, tachycardia, S1, S2 heard, no murmur or added sounds. No lower limb swelling.

Lymphatics: left and right palpable inguinal nodes. No splenomegaly.

 

Diagnostics/Labs

Chest radiograph- to assess the chest and rule out any consolidations (Katz & Williams, 2018). Help in the diagnosis of pneumonia

Mantoux test- screening for pulmonary TB.

Gene expert- detect mycobacterium tuberculosis and help in making TB diagnosis (Thomas, 2017).

Complete blood count- assess the level of neutrophils, lymphocytes, platelets, and red blood cells. High WBC indicates an active infection (Htun et al., 2019). Lymphocyte rises in viral infection. Monocytes rise in allergic reaction and help in the diagnosis of asthma.

Sputum culture- to identify disease-causing micro-organism

C-reactive protein-raised CRP indicates the presence of an infection (Katz & Williams, 2018).

ASSESSMENT:

Priority diagnosis- upper respiratory tract infection

Differential Diagnosis;

Pulmonary tuberculosis- patient presents with a chronic cough> 4 weeks, associated with night sweats, and weight loss. History of contact with TB patient. These features and palpable cervical, inguinal, and axillary lymphadenopathy support the likelihood of TB (Furin, 2019). Thinning of hair also indicates a chronic immunodeficiency state.

Asthma- diagnosed with asthma at 3 years and has a family history of asthma. Auscultation reveals wheezing and is allergic to pollen grains. He is also exposed to cigarette smoke which may exacerbate his symptoms. Presences of an allergen, cough, exposure to smoke, and wheezing are indicative of asthma (Quirt et al., 2018).

Pneumonia- he has chest pain, cough, fever, shortness of breath, and tenderness on palpation. He has had previous attacks of the same leading to admissions. Fever indicates an infectious process supported by a productive cough (Hill et al., 2019). Shortness of breath may also indicate the severity of pneumonia.

Dani Rivera Pediatric Cough Soap Note Paper References

  • Furin, J. (2019). Advances in the diagnosis, treatment, and prevention of tuberculosis in children. Expert Review of Respiratory Medicine13(3), 301–311. https://doi.org/10.1080/17476348.2019.1569518
  • Hill, A. T., Gold, P. M., El Solh, A. A., Metlay, J. P., Ireland, B., Irwin, R. S., & CHEST Expert Cough Panel. (2019). Adult outpatients with acute cough due to suspected pneumonia or influenza: CHEST guideline and expert panel report. Chest155(1), 155–167. https://doi.org/10.1016/j.chest.2018.09.016
  • Htun, T. P., Sun, Y., Chua, H. L., & Pang, J. (2019). Clinical features for diagnosis of pneumonia among adults in a primary care setting: A systematic and meta-review. Scientific Reports9(1), 7600. https://doi.org/10.1038/s41598-019-44145-y
  • Katz, S. E., & Williams, D. J. (2018). Pediatric community-acquired pneumonia in the United States: Changing epidemiology, diagnostic and therapeutic challenges, and areas for future research. Infectious Disease Clinics of North America32(1), 47–63. https://doi.org/10.1016/j.idc.2017.11.002
  • Quirt, J., Hildebrand, K. J., Mazza, J., Noya, F., & Kim, H. (2018). Asthma. Allergy, Asthma, and Clinical Immunology: Official Journal of the Canadian Society of Allergy and Clinical Immunology14(Suppl 2), 50. https://doi.org/10.1186/s13223-018-0279-0
  • Thomas, T. A. (2017). Tuberculosis in children. Pediatric Clinics of North America64(4), 893–909. https://doi.org/10.1016/j.pcl.2017.03.010