Pediatrics H&P

History and Physical – Rotation 2

Siddharth Shah
Rotation 2 – Pediatrics

Identifying Data

February 7th, 2023 – 10:40 AM
JM 4, Hispanic Queens, NY
Informant: mother, reliable

Chief Complaint: “Cough, congestion, and fever”

History of Present Illness:

4 y/o male born full-term BIB mother presents c/o cough, congestion, and fever for 3 days. The patient mother took temperature yesterday on forehead and was 101F. The patient mother is endorsing rhinorrhea, and patient attends day care. The patient mother denies giving any antipyretic and brought him to see the doctor as the day care won’t allow the child back until cleared by the doctor. Patient has no siblings, and mother denies nausea, vomiting, and diarrhea.

Past Medical History:

  • No Past medical history

Past Surgical History:

  • No surgical history

Medications:

  • Denies

Allergies:

  • NKA

Vaccinations:

Up to date

Family History:

  • Father: 35 Alive and well, no known medical conditions
  • Mother: 33 Alive and well no known medical conditions

 

 

Social History:

  • Lives at home with mom, and dad, no smokers.
  • No recent travel

 

Review of Systems:

General: Appears alert and orientated, slightly uncomfortable, and tired.

Skin: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, or changes in hair distribution.

Head: denies headache, and vertigo.

Eyes: Denies visual disturbances, double vision, blurriness, excess tearing or dryness, photophobia, or pruritis.

Ears: Denies hearing loss, tinnitus, discharge, earache.

Nose and sinuses: Patient has discharge, and runny nose.

Mouth and throat: Denies sore throat, bleeding gums, ulcerations.

Neck: Denies localized swelling, lumps, stiffness, or decreased range of motion.

Pulmonary: Endorses cough. Denies shortness of breath, denies wheezing Denies hemoptysis, cyanosis.

Cardiovascular: Denies chest pain, palpitations, edema, irregular rhythms.

Gastrointestinal: Denies changes in appetite, intolerance to any foods, no vomiting/dysphagia or pyrosis. No constipation or abdominal pain.

Genitourinary: Denies incontinence, dysuria, nocturia, urgency, oliguria, or polyuria.

Nervous: Denies seizures, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory, or weakness

Musculoskeletal: Denies joint pain, swelling, weakness, changes in range of motion, or instability.

Peripheral Vascular: Denies peripheral edema. Denies intermittent claudication.

Hematologic: Denies History of DVT/PE, and leg swelling.

Endocrine: Denies heat/cold intolerance, excessive sweating.


Physical Exam:

General: Patient lying on bed appears tired, and ill. He is well groomed, and well-developed for age.

Vitals:

  • BP(Seated): R – 106/68
  • P: 107, regular
  • R: 22breaths/min, unlabored
  • T: 100.F, Forehead
  • Height: 42 inches: 42 lbs – BMI: 27.4

Skin: Warm and moist throughout. No erythema. No jaundice.

Hair: Average quantity and distribution.

Nails: No clubbing, capillary refill <2 seconds in all four extremities

Head: Normocephalic, atraumatic, nontender to palpation throughout.

Eyes: Symmetrical OU. No strabismus, exophthalmos, sclera white, cornea clear, conjunctiva pink.

Nose: B/l erythematosus nasal congestion.  Symmetrical and no masses, lesions, signs of trauma or discharge noted. Nares are patent bilaterally and nose is non tender to palpation

Ears: Slight wax b/l. No masses, lesions, or deformities on external ears.  No discharge or foreign bodies in external auditory canals AU. TM’s white and intact with light reflex in good position AU.

Mouth:

  • Lips: Pink and moist with no lesions
  • Mucosa: Pink with no masses or lesions. Non-tender to palpation.
  • Palate: Intact with no masses or lesions non-tender to palpation; continuity intact.
  • Gingivae: Pink. No hyperplasia; masses; lesions; erythema or discharge.
  • Tongue: Pink; well papillated with no masses or lesions. Non-tender to palpation.
  • Oropharynx: Erythematous tonsils, no exudates.

Neck: Trachea midline. 2+ Carotid pulses, no stridor, thrills, or bruits noted bilaterally.

Thyroid: Nontender to palpation, no masses, no bruits noted.

Chest: Symmetrical, no deformities or trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout.

Lungs: On auscultations crackles heard b/l

Heart: Carotid pulses are 2+ bilaterally without bruits. RRR, S1 and S2 are distinct with no murmurs, S3 or S4.

Abdomen: Abdomen is symmetric without striae, no pulsations. Bowel sounds normoactive in all four quadrants. Non-tender to palpation or percussion throughout. No guarding or rebound tenderness.

Genitourinary: Patient is circumcised

Musculoskeletal: No erythema, soft tissue swelling, or tenderness present on bilateral upper extremities.  FROM of all upper and lower extremities bilaterally. No evidence of spinal deformities

Neurologic: All cranial nerves are intact

 

Differential Diagnosis:

  1. Bacterial infection – strep throat
  2. Upper respiratory infection
  3. COVID

Assessment: 4 y/o M born-full term BIB mother presents for cough, congestion, and fever for 3 days.


Plan:

  • Get throat culture.
  • Give Tylenol to reduce fever
  • If throat culture comes back positive start 7-day course of Zithromax.