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Asked by kayladuh7

Patient Info:    Michael is a 7-year-old established patient last seen 2 months ago for well-child visit.  He is accompanied by his mother. 

Chief Complaint:            “My ear really hurts.”

History of Present Illness:   Family has been at Disney World and flew home 2 days ago.  Mom reports that Michael developed cold symptoms 2-3 days before returning home.  Woke during the night, tearful, and complaining of right ear pain.

Past Medical History:     Environmental Allergies

                                            Recurrent episodes of OM as a toddler

Past Surgical History:    Adenoidectomy and myringotomy tubes 2014

Family History:               Both parents alive and healthy; 4-year-old brother with asthma

Allergies:                          Environmental; no drug or food allergies

Medications:                    Loratadine 5 mg daily; daily multivitamin

Immunizations:               Up to date for age

Social History:                Lives with parents and brother in a single family home in suburban community. Is a first grader in a community public school where he does well and has many friends.  Father is a smoker and tries to smoke outside the home. Mother is stay-at-home mom.

Physical Exam:     
Vital Signs:  BP: 84/56      HR:  94        RR:  20      Temp: 100.8     Wt: 44 lbs (25th %)         Ht: 48″ (50th %)

 

STUDENT RESPONSE:

What other questions in the HPI would you ask and why?
Location: 
Quality: 
Severity: 
Duration:
Timing:
Context:
Modifying factors:
Associated signs & symptoms: 

 

 What ROS body systems would you ask about to solicit pertinent positives and pertinent negatives (use CMS categories), and why?
Constitutional/general:
Eyes:
Ears/Nose/Mouth/Throat:
Cardiovascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Integumentary/Skin/Breast:
Neurological:
Psychiatric:
Endocrine:

 

 What other physical exam organ system categories would you include on your exam, and why are each of the elements important? What do they contribute to the formulation of your diagnosis? What are you looking for, or looking to ensure something is not occurring or is present? 
Constitutional Symptoms: Patient is febrile (100.8°F) on arrival. The patient woke in the middle of the night tearful and complaining of right ear pain.
Cardiovascular: Patient is slightly hypotensive (SBP <97) Respiratory: SCIENCE HEALTH SCIENCE NURSING NU 745