Clinical Case Study 4 A.M. is a

Clinical Case Study 4 A.M. is a 5-year-old boy who presents to the clinic with his father. The family adopted a dog from the animal shelter 8months PTA.A.M.’s father reports that A.M. has had “sneezing fits,” a runny nose, and coughing for the past few months and that itseems better when A.M. is at school. Father states, “He just won’t stop rubbing his nose and eyes.” Vital signs: Temp98.6° F (37° C). BP 93/60âmmâHg (sitting). Pulse 90âbpm. Resp 24/min (at rest, open-mouthed). General appearance:Alert and active child who is smiling and talkative. HEENT: Normocephalic, no lumps, no lesions. Palpable anteriorcervical lymph nodes (1âmm), discrete, move easily, nontender. Light-blue areas in skin under eyes, creasing present onpalpebrae inferior and superior to the tip of nose. Minimal fluid in middle ear, denies tenderness to palpation of sinuscavities; swollen turbinate bilat, and consistently sniffles and clears throat. Reddened posterior pharynx exudate present.Cardiovascular: No murmurs or abnormal heart sounds.Respiratory: Breath sounds = bilat, expiratory wheezing present bilat that clears with cough Fill out assessment form below: Date and time: Subjective (4 pts): Basic Biographic Data Medications Allergies Chief Complaint Symptom Analysis Objective (4 pts): Components of assessment for particular system including inspection, percussion, palpation, and auscultation as appropriate for this system Identify actual or potential risks (2 pts) Actual or potential risks in this system and why did you identify each? Score: _____/10

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