Daniel DeMarco Focused H&P#3 Pediatrics

Chief Complaint: Left Eyelid Swollen x 2d

 

History of Present Illness:

 

JR is a 7yo female, otherwise healthy, complaining of left eyelid swelling x 2d. The eyelid swelling began yesterday and has progressively gotten larger. It involves both the upper and lower lids. Mother gave the patient benadryl yesterday which helped with the itching but not the swelling. Admits itching. Denies vision changes, pain, eyelid crusting, discharge, fever.

 

Immunizations: UTD.

Allergies: NKDA

Medications: Denies

PMH: Denies

PSH: Denies

Social History: Lives with mother, father, and two siblings at home. Mother and father are nonsmokers.

Family History: Denies

 

Review of Systems:

General: Denies fever, anorexia, weight loss, weight gain, change in activity level 

Neuro: Denies HA, trauma, LOC, seizure activity, developmental delays 

HEENT: Admits pruritus of left eye. Denies change in vision, hearing, photo/phonophobia, neck pain, runny nose, ear pain, sore throat

CV: Denies shortness of breath, sweating, color changes with feeding, chest pain, palpitations, recent history of murmur, fainting, or dizziness with activity 

Respiratory: Denies cough, wheezing, shortness of breath

GI: Denies nausea, vomiting (bloody/bilious), diarrhea, constipation, hematemesis, hematochezia, or melena; describe stooling habits 

GU: Denies dysuria, frequency, urgency, hematuria

Endo: Denies polyuria/polydipsia, heat/cold intolerance, growth pattern abnormalities

MS: Denies myalgias, arthralgias, trauma, limp, weakness

Skin: Denies rashes, bruising, petechiae 

 

Physical Exam:

Vital Signs:

BP: 100/64

Pulse: 96bpm

RR: 18 breaths/min

Temp: 36.5C

SpO2: 100%RA

Ht: 49 inches

Wt: 24.0 kg

 

General Survey: Alert, interactive, responsive. NAD.

Skin: No petechiae, masses, lesions. No jaundice, cyanosis, mottling. No rashes.

Hair: Average quantity and distribution.

Nails: Capillary refill <2s throughout.

Head: NC/AT. Non-tender to palpation throughout.

Eyes: Left upper and lower eyelid with erythema and edema. Minimal tenderness to palpation. No crusting on lashes. No discharge. PERRLA. EOM intact and nonpainful. Red reflex present bilaterally.

Ears: External ear with no masses, lesions. Nontender to palpation. Auditory canal with no injection. B/L TMs pearly gray with cone of light in appropriate position.

Nose: Nares patent. Mucosa pink. Septum midline. Turbinates non-boggy, non-hyperemic.

Throat: Good dentition. Gingiva without lesions, masses. Uvula midline. No tonsillar swelling. 

Neck: Supple. No thyromegaly. No lymphadenopathy.

Cardiovascular: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Chest and Pulmonary: Symmetrical rise and fall of chest wall. No labored breathing, accessory muscle use. Clear to auscultation bilaterally.

Abdomen: Nondistended. BS +. Soft, non-tender. No guarding, rebound tenderness. No hepatosplenomegaly.

 

Assessment/Plan:

JR is a 7yo female with left eyelid edema, erythema, and minimal tenderness to palpation concerning for preseptal cellulitis.

 

#Preseptal Cellulitis

– Amoxicillin-clavulonic acid 500mg PO bid x 7d (45mg/kg per day divided q12h x 7d)

 

Follow-Up: Return to clinic in 1 week or sooner if worsening symptoms. Advised to return if fevers, eye pain, etc.

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student