28 Dec What other historical

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 4 Discussion

Diagnostic Reasoning and Advanced Physical Assessment

Module 4 Case Study

K.H. is a 16 year old male who presents to your exam room with recurrent episodes of dyspnea. His mother is with him and reports he has been in his usual good health until this past fall football season ( 4 months ago), when she noticed him wheezing after activities. Usually the wheezing would resolve spontaneously after a couple of minutes of rest. When you ask K.H. how often he feels SOB, he states it has gotten worse and now even walking up a flight of steps causes wheezing and coughing. He also admits to increased fatigue with decreased exercise tolerance.

PMH: Croup as an infant. Recurrent URIs as a child. Immunizations are Up To Date.

Surgical History includes PE tubes at age 3 for chronic OTM (Otitis Media)

Medications: None Allergies: Amoxicillin (hives)

SH: Breast fed x 6 month. Normal Developmental Milestones.Currently in grade 10 at local high school. Active in sports (football, baseball) Grades: As and Bs. + Smoking 3-4 cigs per day x 1 year. Neg for ETOH (alcohol)

Denies illegal drugs. Lives at home with both parents and sister

FH: Mother living @ age 36 with Hypertension and Hypothyroidism – Asthma, – Pneumonia – Smoking

Father living @ age 40 with GERDS -Asthma -Pneumonia + Smoking 1 ppd x 10 years

Siblings: 1 Sister age 13 with recurrent URIs

ROS:

General: No weight changes, fever, chills

Head: No trauma, headaches, hair loss

EENT: No vision changes, earaches, no hearing loss, no congestion, nosebleeds, sore throat or hoarseness

Neck: No dysphagia, swollen glands or stiffness

PUL: + SOB, + Wheezing, + Cough No sputum or sneezing

CAR: + chest pain, worse with deep breaths, No palpitations, swelling. Sleeping sitting up x 1 week.

GI: Not eating well x 1 week. No N/V/D/ Constipation

GU: No urinary frequency, pain or incontinence, or discharge

PVD: No leg pains, numbness or tingling

HEME: No bruising or bleeding

PSYCH: Alert, Oriented, Cooperative. Appropriate thought content and process.

WT: 150 lb s HT: 5’5 BMI: BP: 135/90 HR: 1000 Resp.24 O2 Sats: 88%

PE: K.H. is a 16 year old male who appears stated age, well groomed with tachypnea and appears anxious.

HEENT: Normocephalic, Atraumatic. Hair is evenly distributed.

Eyes: Symmetrical, sclera and conjunctiva normal color PERRL

Ears: Auricles equally symmetrical, non-tender. TMs clear with normal structures. Weber: Equal lateralization

Rinne: AC> BC bilaterally. Nares patent. Turbinates pale. Pharynx: Clear. Good dentitian. Uvula midline. Tonsils pink without enlargement

Neck: Trachea midline Neg for Thyromegaly or nodules. Neg: Carotid Bruits Neg: JVD + Lymphadenopathy

Lungs: Inspiratory/expiratory wheezes 2/3 lobes with decreased breath sounds @ bases. Cough induced with deep inspiration. Hyper-resonance with percussion. Fremitus decreased at the bases. Mild anterior retractions noted.

Cardiac: Reg S1S2 with early systolic murmur @3-4 ICS (intercostal space) MCL (Mid clavicular line).PMI @ 4th MCL w/o thrills

Abd: soft, non-tender, BS x quads. No masses, No scars Neghepatomegaly Neg Splenomegaly

Ext: Diaphoretic, Pale, Neg Clubbing, Pale, sluggish capillary refills .FROM (Full Range of Motion) all extremities

Psych: Anxious, frequently looking at mom to help with answers and during the exam. Alert, Cooperative, Oriented x 4. Subdued Mood.

What other historical information would you like to ask? What are the initial H & P “red flags” are cause for concern? What diagnostic tests/interventions would you perform? What would you include in your differential?