A FOCUSED HISTORY AND EXAMINATION OF DANNY RIVERA

Danny Rivera is a cooperative, pleasant 8 year old Puerto Rican male who presents to the clinic with a chief complaint of cough with fatigue
from lack of sleep.
He states that the cough began five days ago. It is occasionally productive, producing a clear, “slimy” mucous without odor. His cough is getting progressively worse. It is accompanied by a constantly runny nose that has worsened since the cough started.
Danny states that the mucous from his nose is also
clear. His cough is worse at night. Danny denies shortness of breath. He says he says he has no pain in his left ear, and 3 out of 10 pain in his right ear. Danny reports 2 out of 10 throat pain but
denies difficulties swallowing. The cough is frequent, every couple of minutes. Danny’s mother gave him some kind of medication to treat his cough with some relief, however the name of the
medication is unknown. Danny denies chest tightness, nasal congestion, headaches, fever, chills,
weight loss, vision problems, difficulty breathing,
or choking episodes. He states he does not have a history of asthma.
Danny, an only child, lives at home with his parents and his grandmother. No one in the home has been ill. His father has a history of childhood asthma. Both of his parents smoke; his father smokes cigars indoors. There are no pets in the home. Danny says he does not have any allergies.
Physical
Tired appearing boy sitting on the examination table.
Because Danny was alone during the examination, his privacy and confidentiality was protected at all times, all questions were
answered to the patient’s satisfaction prior to proceeding, and his dignity was maintained
throughout the visit. Respiratory illnesses are a top cause of hospitalization of young children in the United States (Maness, 2016). What initially appears as a run of the mill cold can actually turn out to be a dangerous virus in reality. In order to provide optimum patient care to Danny, a thorough focused examination of the head, lungs, eyes, ears, and throat was performed. Right and left eye areas were examined. Lids, sclera, and conjunctive were normal, but with dull appearance. His eyes are not sunken. Bilateral nares are red with boggy turbinates and clear mucous. The left tympanic membrane is normal with a pearly gray tympanic membrane and positive light reflex. The right tympanic membrane is red and opaque. Danny’s neck is normal. His anterior and posterior chest walls are symmetric with no deformities or lesions. Inspection of the oral cavity with a tongue blade reveals cobblestoning in the back of the throat. The patient’s anterior lung sounds were auscultated over all anterior fields with normal results and no adventitious breath sounds. The sounds of the patient’s posterior chest wall were auscultated with normal results; no adventitious breath sounds. Anterior and posterior broncophony revealed muffled sounds over all anterior and posterior fields. Percussion of anterior and posterior chest wall was resonant over all fields. The patient denied pain or discomfort upon palpation of frontal
and maxillary sinuses. Palpated fremitus normal over anterior and posterior chest wall. Right supraclavicular lymph node is enlarged and tender.The patient’s vital signs at the appointment were:
Blood pressure: 120/76
O2 Saturation: 96% R/A
Pulse: 100
Respiratory Rate: 28
Temperature: 37.2 C
Spirometry
: FEV1

3.15, FVC

3.91 = 80.5%
Clinical Reasoning and Differential Diagnosis
Because Danny reports that he has had the cough for five days, it should be classified as acute and a virus, bacteria, or allergies should be considered as possible causes (Dains, Baumann, & Scheibel, 2012; Crampton, 2013). While Danny’s vital signs do fall within normal limits for his age, they are at the upper limit of normal. His O2 saturation is slightly decreased. Decreased oxygenation may be an issue for Danny. Because the patient’s nasal and expectorated
mucous are clear and without odor, virus and allergies are corroborated (Dains, Baumann, & Scheibel, 2012). An increase in the light smoking rates of Puerto Rican men and women supports the finding of both of Danny’s parent’s smoking and, therefore, his exposure to smoke (Blanco et al., 2014). Taking these factors into consideration and based upon the patient’s presentation, my differential diagnoses for Danny are asthma, strep throat, rhinitis, allergies, and a cold.
Plan of Care
Danny’s plan of care will f Danny’s plan of care will focus on continuing to narrow down the cause of his symptoms.
A swab of the back of Danny’s throat will be sent to the lab for culture
to rule out strep throat. A consult to an allergist will be ordered. Danny will be ordered a prescription for an antitussive
and given a not to stay out of school for a few days so that he can stay home and rest. Danny’s parents both work and he is cared for by his grandmother a great deal of the time. Danny’s home is bilingual. A language comprehension evaluation will be done prior to giving post
-care instructions and they can be given in English and Spanish if needed. Danny’s grandmother will be instructed on administering Danny’s medication and in the importance not giving him any
more of the unidentified medicine that his mother gave him while he
is on prescription medication. The importance of no one smoking in the house will be emphasized. Danny will be given his pneumonia vaccine to update his shots. A followup will be scheduled for one week.

 

 

 

 

 

 

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