Week 5 - Focused Exam: Cough Danny Rivera

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Week 5 - Focused Exam: Cough Danny Rivera Subjective 8-year-old Latino male patient presents today with abuela (grandmother) for c/o cough the past 5 days, sore throat since yesterday along with righ... t ear pain. denies fever, chills, HEENT: denies headache or dizziness, EYES: vision unremarkable, denies eye pain, drainage or redness. EARS: +pain- right ear- 3/10, denies drainage or hearing loss, NOSE: denies sinus pain, +clear thin nasal drainage, reports almost always has runny nose, worse since cough started. THROAT: sore, 2/10, reports started after cough. ROS Objective Assessment Differential Diagnoses 1)Upper Respiratory infection 2)Ear infection 3)Pneumonia Lab- CBC, rapid strep test, Chest x-ray, sputum culture Plan Based on labs/diagnostics- antibiotics versus symptomatic care. relieve cough, rhinorrhea, ear and throat pain. humidifier, Tylenol/Advil, cough suppressant/expectorant. return PRN for new or worsening sx's- n/v/d, febrile, increased malaise/fatigue. Rest, eat regularly, hydrate with water, take medications as directed, continue with multivitamin- instruct caregiver to monitor to make sure patient only takes as directed. Wash hands frequently, avoid smoke exposure, refer ENT for frequent rhinorrhea/past HX frequent ear infections eval. [Show More]

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