Document: Provider Notes – NURS 6512

Name:

Danny Rivera

Focused Exam: Cough

Danny Rivera is an 8-year-old male of Puerto Rican descent brought to the clinic by his Abuela because he has been feeling sick.

Subjective:

Chief Complain: Presents with a cough, runny nose, and right ear pain.

Allergies: No Known Allergies to drug, food, seasonal/environmental.

HPI: Danny’s cough began 4-5 days ago. His cough is constant, and he describe it as “gurgly and watery”. He reports occasional clear sputum. His cough has been keeping him up at night and “made it hard to fall asleep” thus making him to be fatigue due to lack of sleep. His mother gave him an over-the-counter cough medication which helped relieved his cough temporally. The name of the medication is unknown but describe it as “purple medicine”. Associated symptoms include a runny nose, mild throat soreness, and right ear pain. His runny nose has clear mucus and started when his cough got worse. He reports frequent cold and runny nose. He also mentioned that he had frequent ear infection as a child and had pneumonia in the past year. His throat soreness is rated as a 2/10 on the pain scale and his right ear pain which started yesterday rated as 3/10 on the pain scale. He denies being around any sick child or person. He denies fever, headache, dizziness, shortness of breath, or difficulties breathing, nosebleed, trouble swallowing, sputum or phlegm, chest pain, aggravation of cough with activity.

Medication: Purple cough medicine this morning that helped a little, but the cough returned. No other medication

PMH: No surgeries or hospitalizations. Reported that his cough always comes around his nose usually gets runny but “never this bad”. Had ear infection as a child. No asthma reported or use of inhaler. Had pneumonia last year and was treated at urgent care.

Immunizations: Current and up to date but has not had the flu vaccine in the last 12 months.

· Hepatitis B series completed at 6 months.

· Hepatitis A series completed at 15 months

· Pneumococcal vaccine at 15 months

· DTAP at 6 years old

· MMR at 6 YEARS

· Varicella vaccine at 6 years

· Polio Vaccine at 6 years

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Medication: Over the counter medication (Purple cough medicine) that helped a little, but the cough returned. He reported a daily children gummy vitamin. No other medication reported.

Social History: Danny is in the third grade and was out of school for two weeks last year because of pneumonia. He lives with Mother, Father, grandmother, grandmother cares for child while parents are working. He is the only child and reported he feels safe at home. He does not really play sports but does play video games with his friend Tony. Primarily speaks English in the house but sometimes Spanish.

Family History: Father is a smoker, and occasionally smoke in the house, hypertension, hypercholesterolemia, Asthma as a child. Mother has type 2 diabetes, hypertension, Obesity, hypercholesterolemia and spinal stenosis. Maternal grandmother has DM2 and hypertension. Maternal grandfather is a smoker, eczema. Paternal grandmother died at age 52 of a car accident. No known history of paternal grandfather.

ROS: Denies fever, reports feeling tired, denies headache, dizziness, vision problems, trouble hearing, recent nosebleed. He also denies difficulty swallowing, breathing.

Objective

Vital signs: B/P 120/91; Pulse 100; Temperature 37.2C, Respiration 28; 02 sat 96%; weight 90lbs; Height 4’2”

Spirometry: FVC: 3.91 L FEV1 3.15 L (FEV1/FVC: 80.5%) Increase respiration at 28 Mild tachycardia is 100 bpm Appears fatigued but appear stable, breath sounds clear to auscultation able to speak full sentences.

HEENT: Head is symmetric and proportioned to body size; Eyes – sclera white, conjunctiva moist and pink, no discharge but appears dull; Ear – right ear is erythema, with the tympanic membrane red and inflamed compared to the left ear; Nose – clear discharge; throat – redness and cobblestoning in the back of the throat. Right cervical lymph nodes enlarged with tenderness.

Cardiovascular: S1, S2, present with no extra sound or murmur, gallops, or rubs.

Respiratory: Normal breath sounds and cleared in all areas on auscultation, respiration rate is increased with no acute distress, speaks in full sentences, no adventitious sounds. Bronchophony is negative. Chest wall is resonant to percussion.

Assessment

Assessment:

1.) Common cold

2.) Strep throat

3.) Rhinitis

4.) Asthma

5.) Allergies due to the abnormal findings affecting the upper respiratory tract, right ear and Lymphatic nodes.

Plan: Perform a strep culture to rule out strep throat. Check with the mother regarding flu shot. Education on mouth covering when coughing and frequent hand washing to avoid spreading germs. Perform lung function test to rule out asthma, and allergy test to rule out allergies. Continue to encourage fluids and avoid dairy products which can make the cough worse. Educate parents on second-hand smoking and to avoid smoking near Danny. Teach Danny to report symptoms to parents if there is no improvement. Ask his mother the name of the cough medication Danny took and document the frequency and the dose. Provide Danny with medication to decrease frequency and help with fatigue from not sleeping, medication for the runny nose, and provide pain relief for throat soreness and right ear pain. Educate family to return in a few days if symptoms is not relieve or get worse.

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