Rotation 1

History and Physical

Identifying data

Name: JH

Age: 7 months

Sex: Female

Race: Hispanic

Date and time: 2/11/2021, 17:15 PM

Location: Pediatric Emergency Department, NYC H+H/ Queens Hospital Center

Source of referral: none

Source of information: Mother, reliable.

Interpreter: Spanish ID # 7200

Chief complaint: Vomiting after formula X 5 months

History of Present Illness:

JH is a 7-month-old female with no significant past medical history. She was brought to the ED by her mother, because she was vomiting formula or curdled milk after being fed with formula. It began after the mother stopped breast feeding at approximately three and a half months of age. She first put the patient on Enfamil regular formula, then Similac, Nutramigen, Enfamil Gentlease, and is currently using Nido. She has tried feeding her daughter regular and soy milk, and all have made her vomit. The vomit is nonbilious non bloody, nonforceful, and occurs after the patient burps. The vomit amount is small, mother states she can catch it in her hands. The patient can eat and tolerate solid food well including carrots, sweet potatoes, and cereal. The mother states she has regular stools, that change in color based on what she ate that day. She admits to occasional constipation. She denies blood in the stool or vomit, diarrhea, fever, weakness, lethargy, sick contacts, or recent exposure to Covid-19. She states she brought her daughter in today because she vomited four-five times, which was more than usual.

JH was born via planned C-section at 39 weeks gestation, weighing 3.13 kg, Apgar score 9/9. No known complications.  JH obtained two sets of vaccines from pediatrician. She last saw her pediatrician 4 months ago prior to the onset of the complaint.

History was obtained from the mother using a Spanish Interpreter.

Past medical History:

Denies past medical history

Denies hospitalizations other than birth

Immunizations:

Hepatitis B: 2 doses, at birth and 2 months

Rotavirus: 1 dose at 2 months

DTaP: 2 doses, at 2 months and 4 months

Hib: 2 doses, at 2 months and 4 months

PCV13: 2 doses, at 2 months, 4 months

IPV: 2 doses, at 2 months and 4 months.

Patient missed third dose of DTaP, PCV13 and IPV at 6 months.

Past surgical history:

Denies surgical history

Medications:

Denies daily medications

Allergies:

Denies allergies

Family history:

Non-contributory

Social history:

JH lives at home with her mother, father and 5 year old sibling.

Review of systems:

General: patient admits to vomiting, denies fever, fatigue.

GI: patient admits to constipation. Denies diarrhea, blood in stool or vomit

GU: normal wet diapers

Physical exam:

Vital signs: blood pressure unable to obtain, Heart rate 140 BPM, regular, respiration rate 28 unlabored. Temperature 99.0, F, rectal.

General: 7 month old female, alert and active, well groomed with good hygiene, dressed appropriately. Patient is not an acute distress.

Head: no scars, trauma

Eyes: pupils equal, round, reactive to light

ENT: proper dentition, no erythema

Cardiac: regular rate and rhythm, no murmurs, rubs or gallops. Normal distal pulses.

Pulmonary: clear to auscultation bilaterally

Abdominal: slightly protuberant abdomen, normal bowel sounds throughout, abdomen soft and nontender

GU: no rashes, cuts, discharge, lesions, or bleeding.

Differential diagnosis:

1. Gastroesophageal reflux
2. Milk protein allergy
3. Gastric outlet obstruction

Assessment:

JH is a 7 month-old female with no significant past medical history, brought to the ED for chronic vomiting after ingesting formula for the past five months. Vomitus is non bilious, non bloody and non forceful. Patient appears well, is alert and energetic. Growth chart review reveals within normal limits in the 74%. Presentation consistent with gastroesophageal reflux.

Plan:

1. Counsel regarding feeding and hydration. Encourage Pedialyte, coconut water and soup broth.
2. Counsel regarding not changing the formula.
3. Referral to GI pediatric specialist at Elmhurst for chronic vomiting
4. Follow up with pediatrician regarding WIC program.

Rotation 1

History and Physical

Identifying data:

Name: JM

Age: 15

Sex: Male

Race: Black

Date and Time: 2/15/21 9:30AM

Location: Pediatric Emergency Department, NYC H+H/Queens Hospital Center

Source of referral: none

Source of information: self, reliable

Chief complaint: “ heart beating on my ribcage” X1 week

History of present illness:

JM is a 15 year-old male, with no significant past medical history, presenting to the ED complaining of his heart beating on his ribcage. He does not currently have any symptoms. He has been having these palpitations on and off for a week. The palpitations are associated with dull chest pain 9/10 radiating from left to right. They get worse when he lies down. The last time he experienced the palpitations was last night as he was trying to sleep. Palpitations are not associated with exercise. Patient admits to chest pain, palpitations, and excessive worry about online school. He denies cough, fever, diarrhea, nausea, vomiting, dyspnea, sick contacts, Covid-19 exposure, syncope, diaphoresis and change in weight. He was brought to the ED by his sister after he told her about his symptoms.

Past medical history: Denies past medical history

Immunizations: up to date

Past surgical history: dacryocystorhinostomy in infancy, unsure of exact date, location or complications. Denies other surgeries.

Medications: denies taking medications on a daily basis

Allergies: patient admits to allergies to pineapple, his tongue and mouth becomes “tingly”. Denies allergies to medications

Family history: paternal grandfather: hypertension. Patient denies any other family history of cardiac disease and other family history. Parents alive and well.

Social history:

Denies use of tobacco, alcohol or illicit drugs.

Patient attends online highschool in his sophomore year, lives at home with his parents and older sister.

Patient often does squats, pushups and planks for exercise. Patient mainly eats starch and carbohydrates.

Review of systems:

General: patient denies fever, chills, nausea, vomiting, diaphoresis, night sweats and changes in weight

Head: patient denies trauma, headache and confusion

Neurologic: patient denies syncope, focal weakness

ENT: patient denies sore throat

Cardiac: patient admits to chest pain and palpitations “heart beating against his chest”, see above. Patient denies known history of murmurs.

Pulmonary: patient denies cough and shortness of breath

GI: patient denies indigestion, diarrhea, difficulty swallowing, abdominal pain

Psychiatric: patient admits to anxiety and stress, denies depression.

Physical exam:

Vitals: pulse 119 regular, BP 134/80 right arm sitting, RR 19 unlabored, temperature 98.2 F orally, pulse ox 100% on room air. Patient weighs 104 lbs, is 5 feet five inches and has a BMI of 18.

General: 15 year-old male, alert and oriented X3, well groomed with good hygiene, dressed appropriately, appears stated age, and in no acute distress.

Head: no deformities, no trauma.

Eyes: pupils are equal, round, reactive to light. No icterus or conjunctival injection

ENT: moist mucous membranes, no erythema, exudate, lymphadenopathy. No thyroid enlargement.

Cardiac: tachycardia at 119 BPM, normal rhythm. No murmurs, rubs or gallops. Radial pulses 2+ bilaterally, capillary refill <2 seconds bilaterally.

Pulmonary: clear to auscultation bilaterally, no adventitious lung sounds

Abdominal: normal bowel sounds throughout, abdomen soft, nontender, no distention.

Differential diagnosis:

1. Hyperthyroidism
2. Paroxysmal arrhythmia
3. Panic attacks/anxiety
4. Anemia

Laboratory tests:

CBC: slightly elevated MCV, MPH, MPV. low WBC, MCHC, RDW and eosinophil. Hemoglobin and hematocrit within normal limits.

THC + 5 panel drug screen: negative

CMP: within normal limits

TSH: 3.41 (reference range: (0.45-4.5)

Imaging:

CXR: within normal limits

Other orders:

ECG: sinus tachycardia

Assessment: JM is a 15 year-old male with no significant past medical history, complaining of paroxysmal palpitations for the past week. Physical exam reveals tachycardia. ECG reveals sinus tachycardia. CXR, TSH and CMP within normal limits, some abnormal findings in the CBC but not concerning. Patient is not in acute distress.

Plan:

1. ECG: sinus tachycardia
2. Drug screen: within normal limits
3. CBC and CMP: non concerning
4. CXR: within normal limits
5. TSH: within normal limits
6.  Discharge with referral to cardiology clinic for follow up
7. Referral to psychologist for anxiety and stress
8. Counseled regarding nutrition