25 Jun Part Two Physical examination
Question
Case study 5: Part Two
Physical examination:
Riley
V/S: Height: 87 centimeters, Weight: 14 kilograms, B/P: 80/48, T: 101 tympanic (no antipyretic), HR: 122 BMP/reg., Resp: 24, regular, SpO2: 98%
General: Somewhat listless, but cooperative throughout exam; rests quietly in his mother’s arms throughout the exam; HEENT: head normocephalic atraumiatic; PERRL., conjunctiva unremarkable; tympanic membranes intact bil; EAC unremarkable; pinna/tragus w/o tenderness; nares patent, mucosa injected, with edema in inferior and medial turbinates bil, and scant clear rhinorrhea; pharynx unremarkable and tonsils are +1/4 bil; neck supple w/o lymphadenopathy bil.
Cardiopulmonary: Heart RRR w/o murmur; lungs are clear to auscultation throughout; abdomen rounded with hyperactive bowel sounds throughout and diffuse tenderness; peripheral pulses reg., equal., intact bil radial and pedal; capillary refill 4 seconds in the finger tips; mucous membranes are sticky, but not overly most.
Jo
Vital Signs: Height: 110 centimeters, Weight: 20 kilograms, B/P:88/60, T: 101.2 tympanic, HR: 108 BMP/reg., Resp: 20, reg, non-labored, SpO2: 99%
General: She is lying on the exam table on her side in somewhat of a fetal position; she refuses to lay supine for her exam as it hurts my tummy; HEENT: head normocephalic atraumiatic, hair thick and distributed throughout entire scalp; conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; nares patent, unremarkable bil; pharynx unremarkable tonsils 2/4 bil; neck supple w/o lymphadenopathy.
Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored.
Abdomen: sl. rounded with hyperactive bowel sounds throughout; guarding to the lower abdomen and rebound tenderness in the right lower quadrant; peripheral pulses reg., equal., intact bil radial and pedal; capillary refill is 3 seconds in the finger tips; mucous membranes are moist.
Discussion Questions Part Two:
Assessment
Primary diagnoses for Jo and Riley with rationale
Differential diagnoses with rationale
Plan for one primary diagnoses based on one current evidence-based journal article.
Further diagnostic work-up not included above
Medications
Referrals
Conservative measures
Patient education
Follow-up plan
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