iHuman michael martinez.PEDIATRICS
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Michael Martinez – Pediatrics CC – Cough Diagnosis – Bronchiolitis by RSV - Upper respiratory infection, influenza, pneumonia, pharyngitis, group A streptococcus, reactive airway disease, br... onchiolitis Tests- Rapid Influenza diagnostic test (RIDT), Rapid strep antigen detection test (RST/RADT), Chest x-ray AP, Respiratory Syncytial Virus (RSV) antigen Problem Statement: ( Demographic description – chief complaint – Hx and PE key findings – risk factors ) Michael Martinez is a 2 year old boy brought in by his mother with complaint of cough. The mother states that the cough had started 2 days prior and is productive of yellow sputum, during this same time the mother reports him having a 102F fever which is ongoing with nasal congestion that has progressed to difficulty breathing and decreased appetite for the past 5 days. Physical exam shows boggy gray nasal turbinates, nasal flaring, intercoastal retractions on inspiration and an expiratory wheeze heard in lower lung fields bilaterally as well as Left submandibular adenopathy. Risk factors include Michael’s father who is a current smoker. (reduce to 70 words) CC: Michael Martinez is a 2 year old boy brought in by his mother with complaint of cough. HPI: The mother states that the cough had started 2 days prior and is productive of yellow sputum, during this same time the mother reports him having a 102F fever which is ongoing with nasal congestion that has progressed to difficulty breathing and decreased appetite for the past 5 days. Meds: Acetaminophen for fever PMH: Noncontributory ROS: Only positive findings are seen in HPI Physical Exam: VS: Pulse – 110; BP – 100/60 RR – 34; T – 102.0F; SpO2 – 92% Skin: Skin tenting seen – indicating dehydration Nose: Nasal turbinates boggy, gray with thick, tenacious yellow drainage bilaterally w/ nasal flaring. Mouth: Palatine tonsils 2+ with erythema Lymphatic: Left submandibular adenopathy present [Show More]
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