Liz Greene has been diagnosed with Asthma, after she has trouble breathing and constantly coughing. This is a SOAP note of her condition. Below there is the history, tests and consultation notes based on her condition.
Patient: Liz Greene
Chief complaint: cough and trouble breathing
HPI: Patient is a generally healthy 5 year old female brought in by her mother with complaints of non-productive cough x2 weeks and moderate trouble breathing x1 week. Mother states cough and trouble breathing which has worsened progressively since onset. Her mother reports that her cough is nonproductive and that she thinks she has heard wheezing recently when Liz is having trouble breathing. Liz's mother denies associated fever. She denies anyone else in the family having similar problems. Liz has no prior history of similar symptoms. Her immunizations are up to date. Physical examination is significant for pulmonary wheezing bilaterally, hypoxia (SO2 93%) and increased respiratory effort.
PMH: None
Medical, surgical, obstetric, hospitalizations:
Normal birth. Full term.
No medical problems.
No major accidents or injuries. No surgeries.
Medications: None Allergies: NA
Preventive Health: Has had regular visits with the pediatrician.
Immunizations:
Birth: Hep B
2 months: DTaP, IPV, HIB, PCV13,Rotavirus, Hep B
4 months: DTaP, IPV, HIB, PCV13, Rotavirus,
6 months: DTaP, IPV, HIB, PCV13, Rotavirus, Hep B, Influenza1st dose 7 months: Influenza 2nd dose
12 months: MMR, Varicella, Hep A 1st dose 15 months: DTaP, HIB, PCV13
18 months: Hep A 2nd dose 24 months: Influenza
36 months: Influenza
48 months: MMR, Varicella, IPV, DTaP, Influenza
Family Hx: Father- Hypertension
Paternal grandfather - Hypertension, Hyperlipidemia
Maternal grandmother - Breast cancer
Social Hx: Lives at home with both of her biological parents. No exposure to second hand smoke. No exposure to illicit drug use.
Review of Symptoms (ROS):
General/ Constitutional: Patient is a generally healthy 5 year old female brought in by her mother with complaints of non-productive coughx2 weeks and moderate trouble breathing x1 week. Denies weakness, fatigue, fever
Skin/Breast: No rashes, no bruising, no petechia
HEENT & Neck: No runny nose or congestion. No eye or ear discharge. No conjunctivitis. No recent head trauma.
Cardiovascular: No history of murmur. No history of fainting or excessive sweating. No chest pain or edema
Respiratory: dyspnea, non-productive cough, wheezing reported. Denies hemoptysis. see HPI.
Abdomen/Gastrointestinal: Denies nausea, vomiting, and diarrhea.
Genitourinary: No history of UTIs.
Musculoskeletal: No recent trauma, no weakness, no limping. Neurological: No history of seizures.
Allergic/Immunologic: No prior testing for allergies. Patient has dog and coughs at night while dog sleeps with patient.
Lymphatic/Endocrine: No history of diabetes, adrenal or thyroid dysfunction Hematologic: No history of anemia
Psychological: Happy Child
Physical Exam (PE):
Vitals:
Temp: 98.6 F
Pulse: 54,
BP: left: 96/64 Respiration: 32
SpO2: 93%
Height: 3'8
Weight: 40 lbs
General: Patient is a generally healthy 5 year old female brought in by her mother with complaints of non-productive cough x2 weeks and moderate trouble breathing x1 week. Denies weakness, fatigue, fever.
Skin: warm, dry, no rash or lesions
HEENT & Neck: Normocephalic, atraumatic. No eye drainage. No conjunctival injection. TMs clear bilaterally. No nasal drainage. OP without erythema or exudate. No tonsillar enlargement. No palpable lymph nodes in the neck.
Thickness and distribution pattern of hair typical for patient gender and age Cardiovascular: Regular rate and rhythm. No murmur, gallop, or rub.
Respiratory: Mild increased respiratory effort, wheezing noted. Lungs CTAB. Thorax normal to percussion. No tenderness, lumps or masses.
All superficial thoracic lymphnodes (axillary, infraclavicular, supraclavicular) are non-palpable or of normal size and consistency .
The anterior lung fields are resonant
The left anterior chest (heart) and right lower chest (liver)are dull to percussion The rest of thelung fields are resonant and are not hyper-resonant
Abdomen/ Gastrointestinal:
Nondistended. Bowels sounds normoactive in all quadrants. Soft, nontender. No pain, tenderness, masses or pulsations
There is no guarding or rebound tenderness No hepatosplenomegaly
Liver span normal
The spleen is not palpable Genitourinary: Normal female genitalia.
Musculoskeletal:
No joint erythema or edema. Normal muscle tone and strength for age. No asymmetry or deformity of the back
No tenderness or spasm of the paraspinal muscles
No localized tenderness of the spinous processes or pelvic structures Psychological: Alert and oriented to person, place, and events Lymphatic/Endocrine: No neck or other regional lymphadenopathy.
Hematologic: No bruising Assessment:
- Wheezing
-Trouble breathing
- Increased respiratory rate (mild)
-Decreased pulse oximetry
-Nonproductive cough
-Sleeps with puppy Differential Diagnosis:
-Asthma (J45.901)
-Bronchitis, Acute (J20.9)
-Pneumonia, bacterial (J15.9)
-Pneumonia, viral (J12.9) Diagnostic Testing:
-ChestX-Ray PA and lateral
-Albuterol nebulizer treatment: Patient given one treatment with nebulized albuterolin the office. After the treatment, her lungs are clear to auscultation bilaterally. Her pulse oximetry improves to 97% and her respiratory rate improves to 22 breaths/minute.
Plan:
-Start Ventolin inhaler2 puffs inhaled every 4-6 hours PRN
-Schedule Pulmonary Function Tests
-Refer patient to an allergist.
-Remove the pet from patient's sleeping area since pets can often trigger asthmatic symptoms. Patient Education:
-Teach the patient's mother how to use a spacer with an inhaler.
Keep a diary of recurrence of asthma and inhaler use to bring to next follow up visit.
-Schedule follow up visit in 2 weeks.
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