URI/Sinusitis Blank (Pediatrics)
CC: cough, congestion Subjective * HPI: Patient X.X. is a XX-year-old male/female who is here for SSs of cough and congestion. She/He is an established patient with the clinic/New patient at the clinic. Patient is present here today with XX. Patient appears fatigued but relaxed, makes good eye contact, and speaks clearly and easily. No SSs of respiratory distress. Drug Allergies: NKDA/Penicillin/shellfish/peanuts * ROS -ENT: Eyes: no corrective lenses or glasses. Ears: denies difficulty with hearing/ C/O ear drainage; denies tinnitus or vertigo. Nose/Sinuses: denies nasal congestion, sinus pressure/pain, and epistaxis/nasal mucosa w/erythema. Teeth: denies issues -Neck/Throat: denies pain, lumps -Cardiovascular: denies chest pain, palpitations, or tachycardia. -Respiratory: denies cough, congestion, wheezing, or dyspnea -Gastrointestinal: denies abdominal discomfort, heartburn, reflux; reports regular voids and stools w/no issues, denies vomiting, diarrhea, constipation Objective * Vitals: HR XX, RR XX Wt XXlb, Ht XX in, BMI XX index, BP XX, Spo2 XX% * Physical Exam General: Child appears age appropriate. Vitals noted and stable. EENT: Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Ears: BOTH EARS: TMs dull w/ effusion, mobile/ TMs w/out effusion, gray, sharp landmarks. Nares: mucopurulent rhinorrhea bilaterally/ clear nasal drainage. Mouth/Throat: Dentition normal for age. Tonsils [2+], non-inflamed bilaterally. Mild erythema noted to pharynx; uvula midline, no petechiae, no exudate Lymph Nodes: No significant lymphadenopathy. Thyroid: No thyromegaly; trachea midline without masses. Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions; dry cough noted during exam Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention. *Labs: FLU A: NEG FLU B: NEG SARS: NEG *Diagnostics: None. PREVENTATIVE HEALTH *Immunizations: UTD. ASSESSMENT/PLAN ACUTE UPPER RESPIRATORY INFECTION, UNSPECIFIED * Discussed the importance of R&R, and increasing hydration to thin secretions. ACUTE COUGH * Discussed the importance of R&R, and increasing hydration to thin secretions. HEADACHE, UNSPECIFIED OTHER FATIGUE * Discussed the importance of R&R, and increasing hydration to thin secretions. Follow-up: 2-3 days w/no improvement -------------------------------------------------------- Some ICD-10s to help: J06.9 - ACUTE UPPER RESPIRATORY INFECTION, UNSPECIFIED J01.90 - ACUTE SINUSITIS, UNSPECIFIED J31.0 - CHRONIC RHINITIS R05.1 - ACUTE COUGH R51.9 - HEADACHE, UNSPECIFIED R53.83 - OTHER FATIGUE
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