Respiratory Case Study Sample

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This is a follow-up visit for [Name], who is a 9-year 6-month-old young man who brought here today, by his mother, for medication management.

REVIEW OF SYSTEMS
Mom reports that [Name] has had itchy eyes and has been sneezing for about 1-month. Mom plans to take him to [Place] for a visit because she thinks he has allergies.

ALLERGIES
[Name] is not allergic to any known food or medications.

_____(INDICATIONS/VACCINATIONS)
Up-to-date.

SLEEP AND APPETITE
[Name] goes to sleep about 9:30 every night after taking his clonidine, and then generally sleeps well until about 5 o'clock in the morning.

Mom reports that [Name] has always, and continues to be a picky eater. It is unclear whether the medication effects his appetite.

MEDICATIONS …show more content…

This is a 7 ounce weight gain since his last visit, about 3 months ago.

VITAL SIGNS
His blood pressure today is 101/62. His pulse is 90. His respiratory rate is 20. [Name] is afebrile.

PHYSICAL EXAMINATION
[Name] is well-appearing today.
ENT: His TM's are _____ with _____. He has no palpable masses or nodes in his neck.
Lungs: His lungs are clear to auscultation.
Heart: His heart has a _____(ir/regular) rhythm and is without a murmur.
Abdomen: His abdomen is soft and nontender, without palpable _____(mass) _____(organomegalia). [Name] has positive bowel sounds.

NEUROLOGIC EXAM
Motor: [Name] has a normal gait. No involuntary movements are known to report.
Mental status: [Name] has a normal aspect. He is oriented and answers questions appropriate.
Cerebellum: No tremors or _____(ataxia). No report.

DIAGNOSIS
1. Attention deficit hyperactivity disorder with hyperactivity.
2. Developmental delays.

PLAN
1. Continue with 1 _____(Viravan) 60 mg capsule every morning with breakfast.
2. Continue with 0.1 mg tablet of clonidine at bedtime.
3. Consider trial of melatonin 1-4 mg at bedtime in place of the clonidine.
4. Return to this clinic in 3 months.
5. Call here with questions or

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