CAUCASIAN MALE CHILD, APPEARS STATED AGE, ALERT AND COOPERATIVE, APPEARS TIRED AND DISTRACTED. SKIN: COLOR IS PALE PINK, NO CYANOSIS OR PALLOR
With furthering questioning of Mom you find that Michael has not wanted to play outdoors. He says he can’t keep up with the other kids in gym class. He says he gets dizzy sometimes too.
PE
VS
Height: 48 inches weight 78 pounds BP 110/70 T 98.2 P 65 R 16.
General
Caucasian male child, appears stated age, Alert and cooperative, appears tired and distracted. Skin: color is pale pink, no cyanosis or pallor. Skin cool, dry and intact. Poor turgor. No moles or skin changes.
HEENT: head normocephalic. Hair thick and distribution even throughout scalp. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender Nose: Nares patent without exudate. Sinuses nontender to palpation.Throat: Oropharynx dry, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored.CV: Heart S1 and S2 noted, RRR, no murmurs, noted. PMI at 5th ICS. Peripheral pulses equally bilaterally. Abdomen: Abdomen round, soft, with hypoactive bowel sounds noted. No organomegaly noted. MS: reflexes WNL. Gait steady.
Labs
CBC:WBC 7, Hgb 14 Hct 40 RBC 4.3 MCV 78 MCHC 34 RDW 11.5
Fasting glucose 136 mg/dL
TSH: 2.6 mIU/L free T4 15 pmol/L
Mary
With further questioning Mary reports feeling more short of breath when doing regular activities, finding it harder to keep up with the kids. Her appetite is less and she is finding it harder to concentrate. At times she feels lightheaded. She says her periods have been heavier since she had her twins but there has been no increased flow or irregular bleeding. LMP was one week ago and lasted four days.
VS
Height: 64 inches, weight 155 pounds BP 115/86 T 99.0 P 62 R 16
General
Caucasian female, appears stated age. Alert, oriented and cooperative. Gait normal. Skin: Skin warm, dry and intact, color is pale pink, no cyanosis or pallor. HEENT: head normocephalic. Hair thick and distribution even throughout scalp. Eyes: .Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. Slight periorbital edema noted. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender Nose: Nares patent without exudate. Sinuses nontender to palpation. Throat: Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Tongue noted to have teeth indentations around the edges. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored.CV: Heart S1 and S2 noted, RRR, no murmurs, noted. Peripheral pulses equally bilaterally. Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly noted.
Labs:
CBC:WBC 8 Hgb 10.1 Hc
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