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Children Health Module 1 Clinical discussion

I started very early before the course for my clinical pediatric rotation and it was very exciting since I am dealing with a different population category. However, the place where I am doing the rotation is not different from the place, I had from the last rotation which helped a lot in easing the transition from the last rotation to this one. I was a little concerned first dealing with children since most of my clinical experience was with adults, but I felt I adapted to this patient category very rapidly.

The patient presented to the clinic this week is a 13-year-old male who came with his mother with a 4-day history of sore throat and productive cough with yellow sputum which started 2 days ago. Symptoms were partially alleviated with Zyrtec and allergy nose spray. The mother requested strep testing. ROS: General: No weight change, generally healthy, no change in activity level. Head: No injury, no bruising. Eyes: Normal vision, no tearing, no pain. Ears: No change in hearing, no bleeding. Nose: nasal congestion, discharge, but no epistaxis, no foreign body. Mouth: No dental difficulties, no gingival bleeding. Neck: No stiffness, no pain, no tenderness, no noted masses. Chest: No dyspnea, no wheezing, no hemoptysis, no cough. Heart: No syncope, no orthopnea. Abdomen: No change in appetite, no abdominal pains, no bowel habit changes, no emesis, no melena. GU: no change in nature of urine. Musculoskeletal: No pain in muscles or joints, no limitation of range of motion. Neurologic: No weakness, no tremor, no changes in mentation. Psychiatric: no changes in sleep habits. Denies fever, vomiting, foreign travel. Not exposed to similar sick contacts. Major events: None. Ongoing medical problems: None. Family health history: Father and mother healthy. Preventive care: Up to date with immunizations including 2021 COVID-19 Pfizer vaccine, but not this year flu. Social history: No smoking, no ETOH, no illicit drugs. Nutrition history: Age-appropriate nutrition. Developmental history: Meeting age-appropriate developmental milestones. Vitals are within normal limits with blood pressure 110/80. Temp is 97.3. Pulse is 77 bpm. The respiratory rate is 18 b/m. Spo2 is. 99%. General Physical Exam: Normotensive, in no acute distress. Head: Normocephalic, no lesions. Eyes: PERRLA, EOM’s full, conjunctivae clear. Ears: Bilateral fluid noted, EACs clear, TMs normal. Nose: Mucosa erythematous, bilateral nasal turbinate are edematous, no obstruction. Throat: slightly erythematous, postnasal drip, no exudates, no lesions. Neck: Supple, no masses, no thyromegaly, no bruits. Chest: Lungs clear, no rales, no rhonchi, no wheezes. Heart: RR, no murmurs, no rubs, no gallops. Abdomen: Soft, no tenderness, no masses, BS normal. Back: Normal curvature, no tenderness. Extremities: FROM, no deformities, no edema, no erythema. Neuro: Physiological, no localizing findings. Skin: Normal, no rashes, no lesions noted. The assessment was done in the office for Strep screen and the result was negative. The plan is as usual to go to the emergency room if there is any worsening of the medical condition and to follow with PCP. A COVID PCR test was sent to the lab for exclusion of COVID and A COVID-19 quarantine education was given to the child and his mother. General education for rest, increasing fluids, warm water gargles, and changing toothbrush in 3 days. Allergy control in the household including changing filters, using HEPA filters, keeping windows closed, removing carpets, and checking the website pollen.com is highly recommended Claritin, Motrin, PRN Benadryl, Flonase spray are recommended (McCance et al., 2017, p.586). Yogurt is also advised while on antibiotic therapy (Dlugasch & story, 2021, p.724). A differential diagnosis of this case includes Allergic sinusitis, step tonsilitis, and COVID-19 infection.

I learned many things during these mainly the differences of pediatric examination and what to look for that is not typically performed in adults plus also the documentation differences.

References

Dlugasch, L., & Story, L. (2021). Applied pathophysiology for the advanced practice nurse. Jones & Bartlett Learning.

McCance Burns, C. E., Dunn, M. A., Brady, A. M., Starr, B. N., Blosser, G. C., & Garzon, L. D. (2017). Pediatric Primary Care. (6th ed.). St. Louis, MO: Elsevier.