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Natacha Pascal-Milfort
Clinical Experience Week 7
My seventh week of clinical experience was very gratifying. I have seen children with different age groups with a variety of
disorders. I enjoyed seen how most parents are knowledgeable and very involved in their kids care. Some of them makes it very
easy to manage their children’s health. I had a wonderful week, I called it “Children ending challenge clinical week”.
Chief Complaint: Runny nose, dry cough for about 3 days.
HPI: M.M. is 15 years old White female got into the clinic with her aunt and stated, “I have a runny nose and a dry cough that
persist for about 3 days”. Patient report that she washed her hair late that night and did not use a blow dryer. pain is 0 on a pain
scale 0-10. Patient has past medical history of Asthma. Aggravating factor is when she takes a cold shower or late shower, when
goes outdoors early in the morning while the pollen is high or cleaning with different chemicals. Alleviating taking Robitussin DM
over the counter. Patient denied History Bronchitis Patient has environmental severe allergy, no known drug/food allergies.
Patient diagnosis Cough is ICD 10: R05
S:
General: Feeling healthy, no change in strength, or ROM no signs or symptoms of distress or discomfort. Head: Denies
headache, dizziness lightheadedness or trauma. Eyes: Denies pain, blurred vision, burning, or any discharge. Ears: Tympanic
membrane pearly gray. Denies change in hearing, no ringing, bleeding, or discharge. Nose: Denies tenderness, nosebleed, or
discharge. Neck: Denies pain, stiffness, or any neck injury/trauma. Throat: Denies sore throat, problem swallowing, coughs, or
itchiness. Lungs: Denies any shortness of breath, chest pain with breathing, chest pressure, or wheezing, admits
cough. Cardiovascular: Denies chest pain, palpitation, chest tightness or any history of murmur. Breast: Denies nipple
abnormality, dominant masses, or tenderness. Abdomen: Denies weight lost, report daily formed bowel movement. Denies any
abdominal pain, distention, bloating, nausea, vomiting, loss of appetite, constipation, diarrhea, or involuntary bowel movement.
Genitourinary: Denies burning sensation, foul odor during urination, incontinence. Female genital: Denies pain, vaginal
discharge, admits currently in menstrual cycle. Musculoskeletal: Denies joints pain, edema, swelling, admits full range of motion.
Neurologic: Patient was well alert and oriented stated her allergies, denies seizures, tremors, numbness, and tingling.
Psychosocial: Denies suicidal thoughts, admits changes in sleep pattern due to the cough.
O:
Height: 5.7 Weight: 162 lbs. BMI: 25.4 BP: 110/71 Temperature: 98.4 (oral) Pulse: 77 bpm Respiratory rate: 15 bpm 02
saturation: 100% Pain: 0/10
General Physical Exam: Alert and oriented x4, dress appropriately for the weather, fair skin turgor, no signs of respiratory
distress. sore throat, mucous membrane pink and moist, no sores, blisters, or mucosal lesions Head: Symmetrical, no palpable
masses, no visible manifestations, no plaques on scalp. Eyes: Normal vision, Pupils are equals, round, reactive to light and
accommodate (PERRLA). Nose: Mucosa non-inflamed, pink, and moist, no septum deviation, epistaxis, lesions, or
discharge. Throat: Tongue and uvula midline, palate intact, and gag reflex present No pain, stiffness, tenderness, bruit, or
masses. Neck: Trachea midline, thyroid non-enlarged and non-tender, no lesions, no jugular vein distention or deformities, no
bruits upon auscultation, lymph nodes non-palpable and non-tender. Lungs: Lungs are clear, unlabored, rhonchi, crackles,
wheezing, or stridor, No finger clubbing, capillary refills less than 2 seconds. rhonchi. Cardiovascular: No chest pains,
palpitations, murmur or syncope, all pulses are palpable. Abdomen: All bowel sounds present x4 quadrants, abdomen soft,
symmetrical non-tender, non-distended, no hernias noted. No abdominal pain. Genitourinary: No bladder distention or
tenderness upon palpation, no urinary urgency, frequency. Female genital: External vaginal clean and intact, no bumps, sores,
blisters, ulcer, or pus. Genitourinary: No bladder distention or tenderness upon palpation. Neurologic: Alert and oriented to
person, place, time and event. No tremors noted, normal sensation to pain, touch, and proprioception. Musculoskeletal: No
peripheral edema or swelling, strength and deep tendon reflexes (DTRs) normal on lower and upper extremities, normal spine
curvature, discomfort noted. Skin: Denies itchiness, unusual bruising, rash, ecchymosis, erythema, lacerations, abrasions, or
prominent lesions. Psychosocial: A/O x 4, judgment and remote memory intact, patient does not appear anxious and in distress,
affect and mood normal, answers all questions accordingly.
A:
Chronic obstructive pulmonary disease (COPD
Gastroesophageal Reflux (GERD)
Upper Respiratory (URTI)
COPD is Chronic obstructive pulmonary disease, or (COPD), refers to a group of diseases that cause airflow blockage and
breathing-related problems.
GERD Gastroesophageal reflux disease (GERD) occurs when stomach acid frequently flows back into the tube connecting your
mouth and stomach esophagus.
URTI Upper Respiratory Tract Infection is a common viral infection that is caused by an acute infection that affects the upper
respiratory tract.
P:
- Start Mucinex DM over the counter1200 mg guaifenesin & 60mg dextromethorphan/1tab PO every 4 hours as needed.
- Zyrtec 10 mg 1 tab PO daily
- Follow up in 2 weeks.
- Rest, increase fluids, no strenuous exercise currently.
- Chest X-ray order
Explanation & Answer
View attached explanation and answer. Let me know if you have any questions.
1
Response to Natacha Pascal-Milfort
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2
Hello Natasha...
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Europe(Continental)