Shadow Health Danny 03.2024
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School
Wilkes University *
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Course
550
Subject
Medicine
Date
Apr 3, 2024
Type
docx
Pages
3
Uploaded by matyzo4
Subjective:
Danny reports a cough lasting four to five days. He describes the cough as “watery and gurgly.” He reports the cough is worse at night and keeps him up. He reports general fatigue due to lack of sleep. He reports pain in his right ear. He is experiencing mild soreness in his throat. He reports his mother treated his cough symptoms with over-the-counter medicine, but it was only temporarily effective. He reports frequent cold and runny nose, and he states that he had frequent ear infections as a child. He reports a history of pneumonia in the past year. He reports normal bowel movements. He denies fever, headache, dizziness, trouble swallowing, nosebleed,
phlegm or sputum, chest pain, trouble breathing and abdominal pain. He denies cough aggravation with activity.
Objective:
• General Survey: Fatigued appearing young boy seated on nursing station bench. Appears stable. • HEENT: Mucus membranes are moist, clear nasal discharge. Redness, cobblestoning in the back of throat. Eyes are dull in appearance, pink conjunctiva. Right Tympanic membrane is red and inflamed. Right cervical lymph node enlarged with reported tenderness. • Cardiovascular: S1, S2, no murmurs, gallops or rubs. • Respiratory: Respiratory rate increased, but no acute distress. Able to speak in full sentences. Breath sounds clear to auscultation. Negative bronchophony. Chest wall resonant to percussion. Expected fremitus, equal bilaterally. Spirometry: FVC: 1.78L, FEV1 1.549L (FEV1/FVC: 87%)
Assessment:
My differentials include cold, strep throat, rhinitis, allergies and asthma based on abnormal findings affecting the ears, upper respiratory tract and lymphatic region.
Plan:
Danny should be referred for an allergy test to rule out allergies as well as a lung function test to rule out asthma. He should receive a strep culture to rule out strep throat. I recommend antitussive treatment at night to help with his sleep in addition to bed rest.
Danny describes the symptoms that have been bothering him.
So how long has your ear been hurting?
Question
06:02 PM
EST
Um . . . I guess my right ear started hurting yesterday, I think.
How often is your runny nose?
Question
06:02 PM
EST
Yeah, um, my nose is runny right now... it always seems a little bit runny.
Any itchy nose?
Question
06:03 PM
EST
Sometimes my nose gets itchy, and I sneeze. But that doesn't happen very much. It's mostly just runny.
Graet
Empathize
06:03 PM
EST
Thank you.
Model Statement:
"I’m sorry your ear and your throat hurt. I’ll take a look and we’ll see if we can
help you feel better."
2 Medications
Followed Up
Description:
Danny describes the medication he was given for his cough.
Have you been taking any medications
Question
05:54 PM
EST
I don't take any medicines every day.
Any fever
Question
05:55 PM
EST
My mom said I didn't have a fever this morning before Abuela took me here.
Graet
Empathize
05:55 PM
EST
Thank you.
Model Statement:
"Thanks for telling me what you know about the medications you take. I can ask your mom or your abuela for more information."
Vitams
Description:
Danny describes taking vitamins.
Model Statement:
"You’re right; taking vitamins can be good
for you. However, sometimes taking too many vitamins can be bad for you. It’d be better if you don’t sneak extra vitamins -- just take the amount that your mom gives you."
Secondhand
Description:
Danny describes
exposure to secondhand smoke at home.
Model Statement:
"That’s too bad your Papi smokes cigars at home. It sounds like it bothers you. Breathing in smoke isn’t very healthy, so it’s good to stay out rooms where you can smell cigar smoke."
Family History
Description:
Danny describes what he knows about his family health history.
Model Statement:
"Thanks for telling me what you know about your family history. You did a good job remembering."
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