Danny Rivera is a 7-year-old Hispanic male presenting with a 3-day history of cough and fever. The following approach was followed while conducting the health assessment of Danny Rivera during Shadow Health Simulation.
Health History.
- Chief complaint: Cough and fever.
- HPI: Persistent cough and sore throat. Positive history of passive smoking and contact with a classmate who had similar symptoms.
- PMH: History of pneumonia when he was younger.
- Medications: Vitamins and a cough syrup that he can’t recall its exact name.
- Allergies: No known Drug Allergies.
- Immunizations: Up-to-date on vaccinations.
Physical Assessment.
- Vital Signs: T: 102°F, HR:110, RR:24, BP:90/60
- General: Alert, oriented, and cooperative.
- HEENT: Red throat with cobblestoning, enlarged tonsils.
- Lungs: Clear to auscultation, no wheezing or crackles.
- Cardiovascular: Regular rate and rhythm.
Danny Rivera’s case highlights the importance of conducting a thorough health assessment and management of pediatric patients. His initial history doesn’t drive the nurse to the actual diagnosis until more details reveal the need to inform him and his family on the importance of handwashing regularly and keeping the home smoke-free.
