A Typical Cold? by Brent J.F. Hill
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Part I—The Initial Physical Examination
Scenario
Mary and Bill adopted a three-year-old toddler named Sam two weeks ago. Sam is good-natured and very inquisitive. Typically, before the finalization of an adoption, children are required to undergo a routine examination by a physician. However, the required examination is not meant to be a complete health screening, and many conditions are not even checked. Therefore, Mary and Bill are bringing Sam to Trinity Medical Center for a standard physical examination by a pediatrician to assess his health status.
Patient History
Very little information was known about Sam’s parents. However, it was known that they died in an automobile accident when Sam’s father suffered a massive heart attack. In the past two weeks Sam has done very well adjusting to his new environment. Moreover, he has had all the proper immunizations for his age.
Sam’s adoptive parents, Mary and Bill, have noticed some greasy/oily stools in his diaper. In addition, they are concerned about his wheezing (when breathing).
Physical Examination
Vital Signs
• Age: 3 yrs., 1 month
• Weight: 28 lbs. (lower 10%-tile)
• Height: 3 ft. 1 inch
• Pulse: 115 beats/minute
• Respirations: 30 breaths/minute
• Blood Pressure: 95/60 (systolic/diastolic) mmHg
General Appearance
• Happy, energetic child
Head and Neck
• Runny nose but his ears are clear of fluid
Lungs
• Cracking sounds are present
• Coughing and wheezing are noticeable
Cardiovascular
• Normal
Abdominal
• No swelling is present
Genitourinary
• Not assessed
Extremities
• Full mobility is present
• Pulse found in arms and legs
Neurological
• Normal reflexes
Physician Comments
Have a complete blood count and chest x-ray done. Also, schedule a follow-up appointment for tomorrow to review the lab results and chest x-ray.
Part II—The Follow-up Visit
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Scenario
Today is Sam’s follow-up medical
Part I—The Initial Physical Examination
Scenario
Mary and Bill adopted a three-year-old toddler named Sam two weeks ago. Sam is good-natured and very inquisitive. Typically, before the finalization of an adoption, children are required to undergo a routine examination by a physician. However, the required examination is not meant to be a complete health screening, and many conditions are not even checked. Therefore, Mary and Bill are bringing Sam to Trinity Medical Center for a standard physical examination by a pediatrician to assess his health status.
Patient History
Very little information was known about Sam’s parents. However, it was known that they died in an automobile accident when Sam’s father suffered a massive heart attack. In the past two weeks Sam has done very well adjusting to his new environment. Moreover, he has had all the proper immunizations for his age.
Sam’s adoptive parents, Mary and Bill, have noticed some greasy/oily stools in his diaper. In addition, they are concerned about his wheezing (when breathing).
Physical Examination
Vital Signs
• Age: 3 yrs., 1 month
• Weight: 28 lbs. (lower 10%-tile)
• Height: 3 ft. 1 inch
• Pulse: 115 beats/minute
• Respirations: 30 breaths/minute
• Blood Pressure: 95/60 (systolic/diastolic) mmHg
General Appearance
• Happy, energetic child
Head and Neck
• Runny nose but his ears are clear of fluid
Lungs
• Cracking sounds are present
• Coughing and wheezing are noticeable
Cardiovascular
• Normal
Abdominal
• No swelling is present
Genitourinary
• Not assessed
Extremities
• Full mobility is present
• Pulse found in arms and legs
Neurological
• Normal reflexes
Physician Comments
Have a complete blood count and chest x-ray done. Also, schedule a follow-up appointment for tomorrow to review the lab results and chest x-ray.
Part II—The Follow-up Visit
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Scenario
Today is Sam’s follow-up medical