Subjective

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University of Texas, Medical Branch *

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6307

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Medicine

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Apr 3, 2024

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docx

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Subjective CC: Pt is an 8 yo hispanic male who presents to the clinic with a chief complaint " I have a cough" History of present Illness Pt denies any recent travel. O: Pt reports starting feeling poorly 5 days prior. L:Pt states that he has a cough. Pt endorses throat pain 2/10 and right uniliater ear pain 3/10. D: Pt states that he ahs been coughing "every 5 minintues or so" for the last 5 days. C: Pt describes the cough as "gurgly and watery" with clear sputum. Pt denies any wheezing or adventitious breath sounds. Cough is present throughout day and worsens at night and makes it hard for him to fall asleep. Cough is acompanied by rhinitis with clear discharge and pharyangitis. Pt denies shortnes sof breath and night sweats. Endorses recent weight gain. A: States cough "stays the same no matter what I do" but endorses a worse feeling at night. R: Endorses mild releif when given OTC cough medications. Pt doesn't know brand. Was "purple" and was given "1 spoonful". T: Consistant throughout day with increasing pain and tussis increasing in the evening. S: Pt endorses mild pain 3/10 in pharynx and 2/10 in right ear. Does not endorse pain associated with cough, only disruptions in ADLs. Past Medical History: Pt has unremarkable past medical history without any surgeries. Pt had one episode on pneumonia last year causing him to miss two weeks of chool. Pt denies any recent viral/bacterial illness or known sick contacts.Pt endorses right unilateral ear pain at 2/10 and throat pain at 3/10. Pt did not receive yearly influenza vaccine. Pt is up to date on all other vaccinations. Family Medical History: Mother - DM2, HTN, HLD, Spinal Stenosis, obesity Father- HLD, HTN, current smoker, asthma as child Maternal grandmother- DM2, HTN Maternal Grandfather- Smoker, eczema, Paternal Grandmother- deceased (52) auto accident Paternal Grandfather- No known history Social History: Pt is an 8 yo male student who lives in a home with his mother, father, maternal grandmother, and maternal gradfather. Father smokes cigars "couple of times" per week in the home. Pt denies having Danny reports a cough lasting describes the cough as “water reports the cough is worse at up. He reports general fatigue He reports pain in his right ear mild soreness in his throat. He treated his cough symptoms w medicine, but it was only temp reports frequent cold and runn that he had frequent ear infec reports a history of pneumonia reports normal bowel moveme headache, dizziness, trouble s phlegm or sputum, chest pain and abdominal pain. He denie with activity.

any pets. Pt denies any prior tobacco use. ROS: HEENT: Pt denies any pain in the eyes, face/sinuses, or mouth. Pt endorses 2/10 right ear pain w/o changes in his hearing. Pt endorses 3/q0 pain in throat without changes in voice. Pt states that his nose "is runny all the time" with a clear dishcarge. Denies any changes in oflaction or taste. Cardiac: Pt denies any chest pain, dizzines, or shortness of breath. Pt denies issues with his heart. Respiratory: Pt denies any shortness of breath. Pt denies any wheezing or use o inhalers. Pt endorses one episode of pnemonia 1 year previously. MSK: Pt denies any pain or problems. GI/GU: Pt denies any issues Skin: Pt denies any issues Psych: Pt denies any problems. Objective Geberal Survey: Pt is an 8 yo male who is fatigued looking. Pt is AOX4 and well nursihed looking. Pt is with his grandmother and she is a relaible historian. Pt is in NAD. Vital Signs: BP 120/76, SPO2 96% RA, Pulse- 100, Resp Rate 28, Temp 37.2 Spirometry: FEV1 1.549L, FVc 1.78, FEv1/FVc :87% : Showing decreased volume of expired air. HEENT: Neck is supple and trachea is midline. Mucus memebranes are moist with clear nasal discharge present. Conjuctiva are moist and pink w/o discharge and sclara is white. Right tympanic membrane is erythematous w/o buldging. Right cervical lymph node is tender and enlarged. CV: S1 &S2 noted throughout all fields. No murmurs, gallops, rubs, S3 or S4 noted on exam. Rate within normal limits. Respiratory: Mild tachpnea of 28 bpm w/o use of accessory muscles. No distress noted. Breath sounds clear in all lung fields and negative bronchopony. Expected fremitis noted and patient and equal rise and fall billaterally of the chest. FEV1 1.549L w/ predicted at 2.22L. FVc 1.78L with predicted at 2.53L highly suspision for asthma or COPD. • General Survey: Fatigued ap seated on nursing station benc HEENT: Mucus membranes are discharge. Redness, cobblesto throat. Eyes are dull in appear conjunctiva. Right Tympanic m inflamed. Right cervical lymph reported tenderness. • Cardio murmurs, gallops or rubs. • Re Respiratory rate increased, bu Able to speak in full sentences to auscultation. Negative bron resonant to percussion. Expec bilaterally. Spirometry: FVC: 1 (FEV1/FVC: 87%) Assessment My differentials include cold, s allergies and asthma based on

Differential Diagnosis: URI, allergic rhinitis, asthma. URI: Mild pharingitis, otitis media concomitant with tussis is highly sugestive of mild infection. Allergic rhinitis: clear nasal discharge and clear sputum from lung fields indeicate drainage, afebrile state further indicates allergic etiology. Asthma: comorbid condition. Previous hx of pneumonia and 1 degree family memeber with astham concomitant with decreased FEV1 and FVC levels are highly suggestive of obstructive pulmonary involvement. affecting the ears, upper respi lymphatic region. Plan Danny should be given Amoxicllin 350mg BID for 5 days for otitis media and possible phrayngitis. Menthol rubs as an antitussive agent for better sleep. Warm salt water gargling PRN would be helpful for pain releif in throat. Strep culture to rule out strep eitology. Danny should be referred to allegist to investigate further allergies. Danny should see pulmonologist and have a full PFT with impulse oscillometry done to see status of lung fuction and to assess asthma and see if there is any reversability in the FEV1 and FVC. Follow-up in 7-10 days if symptoms do not improve.

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