Treatment Of Respiratory Illness In Children And Adults Essay Paper
History of present illness (HPI): Patient presents with a cough that began a week ago. He’s reported that his cough worsens when sleeping at night. He also claims he feels exhausted because he reports that he stays awake at night due to coughing. He identifies the cough as watery and gurgly. He also mentioned having clear sputum. He reports that the severity of the cough is 6/10 and its frequency is every 5-10 minutes. He says that cough does not change even when engaging in activity. He mentioned having sore throat, a 3/10 pain. He mentioned 4/10 pain in the left ear. No trouble swallowing. He reports running nose and clear discharge. Patient mentions not experiencing any recent fever. He also claims he has not experienced any symptoms similar to those of pneumonia. Patient’s mother provided cough suppressants that provide some relief. He reports that his bowel movements have not changed. He denies headache, breathing difficulty, dizziness, and abdominal discomfort Treatment Of Respiratory Illness In Children And Adults Essay Paper.
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Allergies: None
Medications: Patient takes an OTC cough suppressant and a daily multivitamin.
Past History: No past surgical history, or prior hospitalizations noted. Childhood illness reported: Measles at age 5.
Patient acknowledges a history of recurrent ear infections at younger age.
Family History: Father: Hypertension. Father: Diabetes Mellitus. Paternal grandfather: died of heart failure aged 72. Paternal grandmother: Rheumatoid arthritis. Maternal grandmother: No known history.
Personal and Social History: Patient is currently lives with his mother, father, and his older sister. He is in the 4th grade, likes school and performs well in his studies. He has many friends from his class. He likes playing soccer and video games. He has a cat as a pet. He denies recent travel.
Immunizations: Immunizations are up to date; no influenza vaccination noted this past year Treatment Of Respiratory Illness In Children And Adults Essay Paper.
Review of systems (ROS)
General: Patient notes increased fatigue due to poor sleep.
Skin: No itches, rashes, or hives
HEENT:
Eyes: No vision problems
Ears: Patient reports pain in the left ear. No hearing problems. No vertigo or ringing in the ears.
Nose: Reports nose is often runny. Increased clear drainage
Throat: Reports some sore throat, and clear sputum.
Neck: No swelling or changes
Respiratory: Reports increased coughing. No wheezing or shortness of breath,.
CV/PV: Denies chest pain.
GI: Denies vomiting and nausea. No bowel changes.
GU: Denies dysuria, polyuria, and urinary problems.
Neuro: denies headaches, trauma, or periods of confusion Treatment Of Respiratory Illness In Children And Adults Essay Paper.
Objective:
Vital Signs:
Temp: 36.7
RR: 27
Pulse: 98
BP: 122/77
Pulse Ox: 95%
Ht. 129cm, Wt. 39.9kg
Physical Exam
Constitutional: Patient looks tired. Appears appropriate.
HEENT: Moist mucus membranes noted. Clear nasal drainage. cobblestoning and redness observed in back of throat. Eyes appear dull, pink conjunctiva. Reddened left tympanic membrane noted.
Lymph nodes: Left cervical lymph nodes appear swollen with noted tenderness.
CV: S1, S2, no rubs, gallops, or murmurs.
Respiratory: increased respiratory rate. Breath sounds clear to auscultation. Chest wall is resonant to percussion. Fremitus noted, and equal bilaterally. No bronchophony.. Treatment Of Respiratory Illness In Children And Adults Essay Paper
Neurological: awake and alert to person, place and time.
Assessment:
Differential Diagnosis:
- Upper Respiratory Infection
- Rhinitis
- Otitis Media
- Strep throat.
- Acute Bronchitis
- Asthma
- Allergies
The differentials are based on abnormal findings affecting the ears, upper respiratory tract and lymphatic regions.
Problem List:
Productive cough
Pharyngitis
Exhaustion
Opaque tympanic membrane of left ear
Rhinorrhea
Plan:
Diagnosis: Upper respiratory infection
Diagnostic tests: Chest X-ray, CBC and WBC count, strep culture
Pharmacology: Antitussive medication during bedtime to relief cough and aid with good sleep.
Education and Health Promotion: Teach the family about the use of medicines. Promote better consumption of fluids. Incentivise relaxation. Educate the family on signs of deterioration of symptoms. Notify the family to report if symptoms do not improve within a few days or if they escalate.
Referrals: lung function test to rule out asthma and allergy test to rule out allergies
Follow-up: Patient and his parent are to have a follow up appointment in the facility after one week for further assessment Treatment Of Respiratory Illness In Children And Adults Essay Paper.
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Conclusion
Overall, I did a comprehensive HEENT and respiratory assessment on Danny. In order to find any defects, I examined his head, ears, nose, and throat. I undertook both subjective and objective assessment and asked all potential questions. As I obtained more subjective information, a more comprehensive objective assessment was made possible. To better rule out problems and establish a differential diagnosis, this procedure was necessary, making it possible to establish an actual diagnosis and a treatment plan.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2014). Seidel’s Guide to Physical Examination-E-Book. Elsevier Health Sciences.
Danny Rivera (2015). Shadow Health [online program]. Retrieved from https://app.shadowhealth.com.
Hogan-Quigley, B., Palm, M. L., & Bickley, L. S. (2018). Bates’ nursing guide to physical examination and history taking.
Short, S., Bashir, H., Marshall, P., Miller, N., Olmschenk, D., Prigge, K., & Solyntjes, L. (2017). Diagnosis and treatment of respiratory illness in children and adults.
Treatment Of Respiratory Illness In Children And Adults Essay Paper