Brief
The patient is known as Daniel Rivera, alias Danny and is aged 8 years. The patient answers all the clinical questions posed to him with good eye contact maintained despite being brought by his grandmother. Dany reports having had a watery cough for the last 4 days, feeling tired, experiences difficulty in falling asleep due to cough, and every time he coughs, his throat hurts. The kid’s mother in the morning gave him some medicine he hardly knows that relieved the cough for a moment before the cough reappeared again (www.shadowhealth.com). Clinical observation shows pain in the right ear since yesterday and the patient has a history of ear infections that occurred at the age of two years. Danny has no chills, fever, or watery eyes but is prone to frequent colds. The patient is not experiencing any chest pain or breathing difficulty and has not reported any allergic reactions due to any medicine or pollen grains or immunization program.
Patient History
The past medical history of the patient (PMHx); having ear infections in childhood. The patient has no surgical history while social history shows; Danny lives with his parents, the grandmother looks after him when his parents are at work, Danny is exposed to passive smoke from the grandmother but does not smoke. The child observes hand hygiene before taking meals or after visiting the washroom. The patient’s family has no history of asthma or allergic reactions. The patient reports having a watery cough that has persisted between 4 to 5 days. The cough gets worse at night making him fail to sleep. Danny reports general body fatigue due to sleeplessness and pain in the right ear (www.shadowhealth.com). He experiences a mild sore throat. Danny reports that the over counter medication given by the mother in the morning brought temporary relief to the cough symptoms. The reports of having frequent colds accompanied with runny nose and suffered ear infections that were frequent as a child. The child reports to have had pneumonia in the last year. Danny reports having normal bowel movements and denies that the cough aggravates due to his engagement in routine activities. The patient denies having fever, difficulty swallowing, dizziness, pain in the chest, has no headache, no sputum, no breathing difficulty, and stomach pain.
Objective Information
Danny looks slightly tired and was coughing during the examination period. The vital signs are; Spirometer – FEV1:3.15L, FVC 3.91L/80.5%.Head; There is enlarged cervical lymph nodes that are tender towards the right side. There is no tenderness on both the frontal or maxillary sinus. The eyes are pink in color and have no discharge. The right ear is red and is inflamed. Danny has no diarrhea or constipation. The nose is clear, there is a watery phlegm that is odorless. Throat – oropharynx: has cobber stone, shows redness with postnasal drip. Lungs: CTA bilaterally with breath sounds that are clear bilaterally in anterior and posterior. Bronchophony shows chest that has negative results with S1 and S2 being audible. However, there is no abnormal heart sounds.
General Impression
The body is fatigued as he takes a seat in the nursing station but looks stable. Head, ear, eyes, nose, and throat (HEENT) examination: Moist mucus membrane, nasal discharge is clear. There is redness and cobblestone at the back of the throat. The eyes appear dull with pink conjunctiva. The right tympanic membrane appears red due to inflammation. The right cervical lymph node is tender and enlarged.
The respiratory Examination shows an increased respiratory rate but no cause for distress (Sharma et al, 2020). The breath sounds are clear while the bronchophony results are negative. The chest wall responds to percussion.
Differential diagnosis
Danny suffers from either flu-like syndrome or cold, strep throat, allergies, allergic rhinitis, and asthma. This is based on not ordinary findings of the ears, lymphatic region, and upper respiratory tract.
Plan
Discusses hand hygiene and protocols when coughing such as cough under the elbows. Administer cough medication to relieve coughing facilitating sleeping at night. Administer antihistamine to clear secretions and advice Danny to take a lot of fluids. Avoidance of dairy products that can aggravate coughing (Tran, & Ditto, 2020). The follow up will occur in three weeks. The patient needs to have an allergy test to test for allergies and, lung function chest for asthma.
References
Sharma, S., Hashmi, M. F., & Alhajjaj, M. S. (2020). Cough. Stat Pearls [Internet].
Tran, B. B., & Ditto, A. M. (2020). Cough: A practical and multifaceted approach to diagnosis and management. Medical Clinics, 104(1), 45-59. https://www.shadowhealth.com/products/health-assessment
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