Date: 01/06/2022
Full name: T.K
Address: Jamaica, NY
Date of Birth: 05/20/2011
Location: Parson Pediatrics (Dr. Arana’s office)
Religion: Christian
Source of Information: Mother
Reliability: Reliable
Source of Referral: none
Mode of Transport: Parent
Chief Complaint: “Vomited at school yesterday”
History of Presenting Illness:
Patient is a 10-year-old male with no PMHx brought into the office by his mother who complaints that he vomited once yesterday while at school and was sent back home afterwards. The patient threw up again at home but today only c/o feeling weak generally. The mother complains that he has not eaten properly since the vomiting started. The patient has not yet received the flu vaccine. The child is also due for an annual routine checkup. The child is currently not on any medications. There are no further complaints currently.
Past Medical History:
– Denies any PMHx
Past Surgical History:
– Denies any Surgical hx or hospitalizations
Medications:
– Not currently on any medication
Allergies:
-No known drug, food or environmental allergies.
Family History:
Mother – 36 years old and alive
Father – 38 years old and alive
2 Brothers and 6 sisters –all healthy
Paternal Grandmother- alive but health hx is unknown.
Social history:
– Lives with parents and siblings.
– Parents deny tobacco use and deny smoking
– Parents deny any alcohol abuse.
– He is in the 5th grade
– He like soccer and plays with friends after school
– He eats fruits and vegetables but also likes other foods like fried chicken, burritos, tacos etc.
Review of system:
General – Poor appetite. Denies fever and chills. Denies Sleep disturbance.
Skin, hair, and nails- unremarkable
Head – denies headache
Eyes – denies lacrimation, itching, pain
Ears – denies ear pain
Nose /Sinuses – denies any change in smell perception
Mouth/ throat – denies any pain
Neck – denies any recent swelling
Breast – did not ask
Pulmonary system – denies difficulty breathing
Cardiovascular system – did not ask.
Gastrointestinal system – change of appetite. Vomiting x 2
Genitourinary system – denies any frequent urination
Menstrual /obstetrical – did not ask
Nervous system – did not ask
Musculoskeletal – denies any weakness in extremities
Peripheral vascular system – denies any swelling around the legs
Hematological – denies any anemia, easy bruising
Endocrine system – denies any increased thirst, loss of appetite
Psychiatric – did not ask
Physical exam:
Vital signs:
Using machine (Left arm while seated) BP: 98/62 mmHg
Pulse: 78 bpm, regular
RR: 12 breaths/min unlabored
T: 98F using forehead
O2 sat: 98% on room air
BMI: Weight: 71lbs, Height: 53.5 inches = 17.44
General: African American male is alert and oriented to place, appears in no acute distress, well nourished. Appears lethargic. Dressed appropriately for weather and age.
Skin, hair, and nails: good skin turgor, no cyanosis, or edema. No spoon nails. Normal capillary refill.
Head: Atraumatic and normocephalic. Hair is black with good distribution. No seborrhea, lice, or mites.
Eyes: PERRLA. Does not wear corrective lenses. No Icterus. No conjunctival injection.
Ears: No swelling behind the ear or erythema noted around the auricle. No tenderness to palpation of the auricle. Cone of light was noted at 7 and 8 O’clock and there is no erythema or fluid noted.
Nose: Patent bilaterally. No polyps or deviated septum noted.
Neck: Supple, Full ROM. No tenderness to palpation.
Throat: Uvula midline, Upper palate rises.
Mouth: Oral mucosa is moist. No erythema or central cyanosis noted.
Pulmonary: Lungs were clear to auscultation Bilaterally. No rales or Rhonchi.
Cardiovascular: Normal S1 and S2 sounds.
Abdominal exam: Abdomen is soft. Bowel sounds present in all four quadrants, No pain with light and no pain on deep palpation.
Breast: Not applicable.
Genitourinary: Could not be performed.
Menstrual and Obstetrical: Does not pertain to the patient
Endocrine system: No goiter
Neuro exam: Normal gait, Intact light touch, sharp/dull sensations. No tics, tremors, or fasciculation.
Musculoskeletal: Full ROM with 5/5 strength in both upper and lower extremities.
Peripheral vascular system: +3 peripheral pulses.
Assessment:
10-year-old male with no PMHx is brought in by mum with c/o of vomiting x 1 day. Pt is covid vaccinated but is due for influenza vaccination. Pt is in no acute distress currently. Pt is also due for routine annual exam.
Differential:
- Acute gastroenteritis
- Food poisoning
Plan:
– Counsel on Brat diet and Rehydration
– Administer Flu vaccine
– Start Acetaminophen solution 10ml orally every 4 hours x 3 days. (prescribed for side effects of flu vaccine.)
– Start Chewable children’s multivitamin
