History and Physical 1

Identifying Data: 

Name: KH 

Age: 5 year old Female 

MR: 4070806 

Race: African American 

Date & Time: 2/08/21 at 12:30PM 

Location: QHC Pediatric Emergency Department 

Source of Referral: none 

Source of Information: self 

Mode of Transport: personal vehicle 

Chief Complaint: “abdominal pain and vomiting for one day” 

History of Present Illness: 

KH is a 5 year old female with a past medical history of sickle cell anemia is brought to the ED complaining of abdominal pain since yesterday. She states that today she has had 3 episodes of vomiting, non bloody, non billious. The vomit contained clear yellow liquid. She has been drinking appropriate amounts of fluid and has had normal urine frequency. She has also been complaining of headaches associated with the stomach pain. Nothing makes the symptoms better or worse. The patient says the pain diffuse all over the abdomen, and comes and goes. She denies any pain with urine, increased frequency, changes in bowel movements, fever, cough, sneezing, rhinnorhea, shortness of breath, rash, upper or lower extremity swelling. Mother states that they have had no contact with anyone with Covid and denies any sick contacts. Mother states that her sickle cell used to be treated with hydroxyurea, but has stopped 2 months ago due to side effects. She denies any other complications due to the sickle cell.  Mom states she takes penecillin occasionally for pain. 

Past Medical History: 

Present illness: 

Abdominal pain and emesis 

Hereditary persistence of fetal hemoglobin 

Sickle cell disease  

Past illness: 

Hereditary persistence of fetal hemoglobin 

Diagnosed: 4/5/2017 

Sickle cell disease  

Diagnosed: 5/13/2016 

Hospitalizations: 

       Denies ever being hospitalized 

Immunizations: 

      All immunizations up to date  

Birth history: 

Patient was born full term at 37 weeks, with no complications. Unknown mode of  delivery 

Past Surgical History: 

1. Denies any past surgeries, injuries or blood transfusions 

Medications: 

      Hydroxyurea for sickle cell: stopped 2 months ago due to side effects  

Allergies: 

      Denies any seasonal allergy, food or medication allergy 

Family History: 

      mother: alive and healthy 

       Father: alive and healthy 

Social History: 

Habits: 

         no at home smoking, alcohol or drug use. 

Travel:  

        No recent travel 

Home:  

        Lives at home with parents 

Diet:  

       Eats a balanced diet 

Sleep:  

      sleeps 8-9 hours a day 

Exercise:  

      child is playful and active 

Safety:  

      KH ses all appropriate safety measures 

Review of Systems: 

General:  

 Negative for fatigue, fevers, chills, night sweats, activity change, appetite change, or  irritability  

ENT: 

        Negative for rhinorrhea, sneezing, congestion, sore throat, pain with swallowing or ear pain  or changes in vision.  

Head: 

       Reports headaches but denies syncope or dizziness 

GI: 

        Positive for vomiting, nausea and abdominal pain. Negative for diarrhea or constipation 

Pulmonary:  

Negative cough, shortness of breath, wheezing, stridor, or chest tightness 

Cardiovascular:  

Negative for known murmur or chest pain 

Musculoskeletal:  

negative for muscle or joint pain  

Neurological:  

positive for headaches   

Physical Exam: 

Vital Signs: 

         Blood Pressure: 101/66 (right arm sitting), HR: 99, RR: 22, O2 sat: 99% room air T: 99F 

Height: unable to obtain, weight: 38lbs, BMI: unable to obtain 

General Appearance:  

KH is active and not in any acute distress. She is normal appearing, well groomed and  appropriately dressed. She is well developed and normal weight for age. Not toxic or ill  appearing 

Skin:  

Warm, noncyanotic, no signs of jaundice. Cap refill is less then 2 seconds, no rash or  lesions 

HENT:  

Head is atruamatic. Ears: tympanic membranes nor erythematous or bulging. Nose  normal, no congestion. Mouth and throat: moist mucu membranes, oropharynx is clear,  no swelling or exudate 

Eyes: 

No icterus, no discharge bilaterally or change in vision. PERRLA.  

 Neck: 

No lymphadenopathy, trachea midline, neck supple 

Lungs:  

Normal breath sounds bilaterally, no respiratory distress, no nasal flaring or retractions. No  decreased movement, stridor, wheezing, or accesory msucle use.  

Cardiac: 

Regular rate and rhythm. S1 and S2 hear, no S3 or S4. No murmurs, rubs or gallops 

Abdomen: 

Abdomen is flat, soft and nondistended. Normoactive bowel sounds. No abdominal  tenderness, guarding or rebound.  No masses or lesions.  

Lymphadenopathy: 

No cervialadenopathy 

Summary: 

5 year old female with a history of sickle cell comes in complaining of abdominal pain and vomiting. Physical shows normal abdominal exam. 

Labs/tests: 

Rapid tests: 

Covid: negative 

Flu: negative 

Urine: no significant findings 

Bloodwork:  

CBC with differential: WBC 20 (H), HGB : 6.9 (L) 

CMP: no significant findings 

Lipase: no significant findings 

hepatic: total bilirubin 50, AST: 56 

Differential Diagnosis: 

1. Generalized abdominal pain 

2. Sickle cell/ Vasoclusive crisis 

3. Viral gastroenteritis 

4. COVID 

Assessment: 

KH is a 5 year old female with a past medical history significant for sickle cell anemia coming in with mom complaining of abdominal pain and vomiting for 2 days. Physicial exam and labs (as mentioned above) are all normal, apart form mildly elevated WBCs. History and exam is consistent with generalized abdominal pain.  

Plan: 

Generalized abdominal pain: 

-IV hydration 

-follow up with PCP 

-hydrate, and supportive care 

Sickle cell 

– follow up with PCP  

– keep up to date with routine check ups 

History and Physical 2

Identifying Data: 

Name: KD 

Age: 20 

Race: African American 

Date & Time: 2/10/21 at 4:30pm 

Location: QHC Pediatric Emergency Department 

Source of Referral: none 

Source of Information: self 

Mode of Transport: personal vehicle 

Chief Complaint: “sore throat for 3 days” 

History of Present Illness:

KD is a 20 year old female with a significant past medical history of asthma (well-controlled) who presents with sore throat and difficulty swallowing food for 3 days. She was seen in the Pediatric ED at QHC in December 2020 for a similar complaint of sore throat and pain with swallowing. She was diagnosed with strep throat at that visit and was treated with Amoxicillin with successful results.  

Today, she reports that she has had sore throat for 3 days now, with a sensation of swollen tonsils. She says that she noticed some white spots on both her tonsils. She says the prior to these symptoms 3 days ago, she had a sensation of stiffness and pain in her neck, but says that that has since resolved. She states that she has also been having some difficulty swallowing solid foods, but is okay with liquids. She states that rest and not talking help alleviate the symptoms, and that talking and swallowing make it worse. She rates her pain as a 5/10. She has associated headache and pain with swallowing, and denies any fever, cough, runny nose, chills, myalgias, sweats, difficulty breathing, chest pain, vision changes or any nausea or vomiting. She states that she has had no sick contacts or interaction with anyone diagnosed with COVID-19.  

Past Medical History: 

Present illness: 

      Asthma-well controlled  

Past illness: 

1. Asthma-diagnosed when she was a child (unsure of year) 

1. Patient states this is well controlled with an inhaler 

Hospitalizations: 

       No hospitalizations reported 

Immunizations: 

      All immunizations up to date 

Past Surgical History: 

1. Mole removed when she was a child 

1. Patient unsure of date and location 

2. No complications were reported 

Denies any other surgeries, injuries, and blood transfusions 

Medications: 

KD is on an albuterol inhaler as needed.  

Last used was several months ago- well controlled 

Allergies: 

Allergy to strawberries and strawberry flavored products. 

Denies any seasonal allergy or medication allergy 

Family History: 

Mother: alive and well 

Father: alive and well 

Social History: 

Habits: 

         denies any tobacco and illicit drug use 

         Reports occasional Alcohol use (socially). States she may have 1-2 beers on the weekend 

Travel:  

        KD denies any recent travel 

Home:  

        KD lives at home with her mother and father 

School: 

Attends college, socializes with friends  

Diet:  

       KD eats a balanced diet, specific foods not reported 

Sleep:  

      KD states she sleeps “normal hours.” Specific number not reported 

Exercise:  

      Exercise history not obtained, but KD reports she stays active 

Safety:  

      KD uses all appropriate safety measures 

Review of Systems: 

General:  

Denies fever, chills, fatigue, weakness, and loss of appetite 

Oral: 

        Reports sore throat and swollen tonsils. Reports white spots on tonsils. Has difficulty                    swallowing solids. 

Head: 

         Positive headache. Denies dizziness and lightheadedness 

Pulmonary:  

Denies dyspnea, shortness of breath, cough, and wheezing 

Cardiovascular:  

Denies chest pain and known heart murmur 

Musculoskeletal:  

Denies joint pain, swelling, deformity, decreased ROM, or any other abnormalities  throughout 

Neurological:  

Reports positive headache. Denies loss of sensation, paresthesia, or numbness 

Physical Exam: 

Vital Signs: 

         Blood Pressure: 112/71 (right arm sitting), HR: 88, RR: 18, O2 sat: 100% room air T:  98.5F 

Height: 5’5”, weight: 127lbs, BMI: 21.1 

General Appearance:  

20 year old female, in no acute distress. Patient is alert and oriented x 3. Well groomed,  appropriate hygiene, and well dressed. 

ENT: 

Patient has positive erythema in the oropharynx, and edema in bilateral tonsils. Both  tonsils are also noted to have white exudate. Mild lymphadenopathy present. Oral mucosa  is moist, proper dentition, trachea midline. Normal hearing bilaterally, no nasal discahrge. 

 Neck: 

Anterior chain lymphadenopathy noted throughout. Neck is supple 

Cardiac: 

Regular rate and rhythm. S1 and S2 hear, no S3 or S4. No murmurs, rubs or gallops 

Lungs:  

Breath sounds nonlabored. Chest is clear to auscultation in all lung fields bilaterally,  no  adventitious lung sounds. Accessory muscles not used, no retractions or nasal                       flaring.  

Labs/tests: 

1. Rapid strep test: 

1. Test results: positive 

2. Throat culture obtained 

1. Awaiting results 

3. Covid PCR test 

1. Test results negative 

Assessment: 

KD is a 20 year old female with as past medical history of asthma, well controlled on albuterol, coming in complaining of a sore throat and tonsillar swelling for 2 days. Physical exam and history is consistent with Strep pharyngitis infection.  

Differential Diagnosis: 

2. Streptococcal pharyngitis 

3. Exudative tonsilitis 

4. Viral pharyngitis 

5. Viral URI 

6. COVID 

Plan: 

7. Strep pharyngitis 

1. Considering patient was on Amoxicillin before, we will switch the antibiotic to erythromycin  

1. 250mg every 6 hours for 10 days. 

8. Asthma 

1. Continue monitoring and use rescue inhaler when needed 

History and Physical 3

Identifying Data: 

Name: AP 

Age: 20 

Race: African American 

Date & Time: 2/10/21 at 5:45pm 

Location: QHC Pediatric Emergency Department 

Source of Referral: none 

Source of Information: self 

Mode of Transport: personal vehicle 

Chief Complaint: “heart burn for 1 day” 

History of Present Illness: 

AP is a 20 year old female with a past medical history of anxiety and asthma that comes in complaining of sensations of heart burn and acid reflux since this morning. She has had these symptoms before in the past and has been seen at QHC numerous times for the same complaint. She has an endoscopy scheduled in the next 3 days as per her PCP.  

Today she reports that she has been having this sensation of burning in her throat after eating any meal. For breakfast she had eggs and for lunch she had a sandwich and chills and had the same burning 30 minutes after eating each meal. She says that she has been having associated stomach pain and chest burning sensation for the past 2 months but has worsened today. She describes the stomach pain as sharp, but intermittent. Eating exacerbates the pain, and rest and not eating a big meal alleviates it. She has not taken any medication for it. She had one bowel movement today but says it was hard stool. She is also having associated nausea, increased belching, fatigue and mild constipation. She denies any fevers, chills, chest pain, vomiting, diarrhea, pain with urination, sore throat or difficulty breathing. She denies any sick contacts, COVID exposure or recent travel. She reports her LMP was 2 weeks ago, and was normal flow and lasted 4 days. 

Past Medical History: 

Present illness: 

      Anxiety 

      asthma 

      GERD 

Past illness: 

1. Anxiety- well controlled, not on any daily medications, but her PCP is aware of her presentation 

2. Asthma- well controlled with albuterol (last taken was 5 months ago) 

Hospitalizations: 

       Patient denies any recent hospitalization, but says she was in the NICU when she was born  for 2 weeks, but is unsure for what reason. She states she was at a hospital outside the  HHC network.  

Immunizations: 

      All immunizations up to date 

Past Surgical History: 

Denies any surgeries, injuries, and blood transfusions 

Medications: 

        Tylenol: as needed for occasional headaches  

         Albuterol: for asthma, as needed rescue inhaler 

Allergies: 

Allergy to peanuts, treenuts and almonds.- gets a rash all over and has difficulty breathing 

Denies any seasonal allergy or medication allergy 

Family History: 

Mother: alive and well 

Father: alive and well 

 Sexual history: 

AP states she is currently sexually active with one male partner 

She uses condoms for barrier protection 

Patient is unsure of last sexual activity, but states its been a few weeks 

She denies ever having been tested for any STDs 

Social History: 

Habits: 

         denies any tobacco, alcohol or illicit drug use. Denies ever vaping or smoking a Hookah 

Travel:  

        AP denies any recent travel, domestic or international 

Home:  

        AP lives at home with her mother and father in a private home 

Occupation: 

       AP is a student in college, studying to be an engineer 

Activities: 

Occasionally goes out with friends, but since lockdown, has been home for majority of  the time. 

Diet:  

       AP eats a balanced diet, eats vegetables and protein and occasional junk food 

Sleep:  

      AP sleeps 7 hours a day, but that varies depending on school work 

Exercise:  

      AP states she is very active, and exercises every day 

Safety:  

      AP uses all appropriate safety measures 

Review of Systems: 

General:  

Patients reports fatigue, but denies fever, chills, weakness, or loss of appetite. 

ENT: 

        Denies sore throat, swollen tonsils, or difficulty swallowing foods. No pain in ears, or 

Changes in vision 

Head: 

         Denies headache or syncope. Denies dizziness and lightheadedness 

GI: 

         AP complains of pain in her stomach, heart burn sensation, nausea, constipation and                     eructation. Denies vomiting, diarrhea, or changes in bowel. 

Pulmonary:  

Denies dyspnea, shortness of breath, cough, and wheezing 

Cardiovascular:  

Denies chest pain and known heart murmur 

Musculoskeletal:  

Denies joint pain, swelling, deformity, decreased ROM, or any other abnormalities  throughout 

Neurological:  

Reports positive headache. Denies loss of sensation, paresthesia, or numbness 

Physical Exam: 

Vital Signs: 

         Blood Pressure: 96/61 (right arm sitting), HR: 91, RR: 16, O2 sat: 100% room air                       T:98.1F oral, Height: 4’11”, Weight: 91lbs, BMI: 18.4 

General Appearance:  

20 year old female, in no acute distress. Patient is alert and oriented x 3. Well groomed,  appropriate hygiene, and well dressed. 

ENT: 

.        moist mucus membranes, proper dentition, normal hearing, no nasal discharge or post                   nasal drip. No erythema, no pharyngeal erythema, no exudates, normal tonsils 

 Neck: 

No lymphadenopathy, trachea midline, neck supple 

Abdomen: 

Mildly hypoactive bowel sounds throughout in all quadrants.. No aortic bruit. Tympanic  on percussion of  all four quadrants. Abdomen is soft, nontender to light and deep  palpation. No distension or hepatosplenomegaly.  

Pelvic exam: 

Not done by physician, but would be contributory since this is a female patient with  abdominal pain. Would check for any cervical motion tenderness, cervical lesions, any  abnormal discharge or erythema. Would also do a bimanual exam to assess the ovaries.  

Lungs:  

Breath sounds nonlabored. Chest is clear to auscultation in all lung fields bilaterally, no                adventitious lung sounds. Accessory muscles not used, no retractions or nasal flaring.  

Cardiac: 

Regular rate and rhythm. S1 and S2 hear, no S3 or S4. No murmurs, rubs or gallops 

Labs/tests: 

No labs or tests ordered as patient has an endoscopy scheduled in 3 days 

Assessment: 

AP is a 20 year old female with a past medical history of anxiety and asthma, well controlled with albuterol. She comes in complaining of heart burn sensation after eating today. She says she has had these symptoms in the past and is scheduled for an endoscopy in 3 days. Physical exam is normal. History and presentation is consistent with Gastroesophageal reflux disease. K 

Differential Diagnosis: 

1. GERD 

2. Gastritis 

3. Achalasia 

4. esophagitis 

Plan: 

5. GERD 

1. Famotidine 20mg BID for up to 6 weeks 

2. Follow up with PCP 

3. Do endoscopy, follow up with PCP pending the results 

6. Asthma 

1. Continue monitoring and use rescue inhaler when needed