Polly Pocket – Pediatrics
CC – Shortness of breath and back pain
Diagnosis – Lymphoma, Myocarditis, Pericarditis, Tuberculosis, Pneumonia/bacterial(NOS),
heartfailure/CHF
Tests- Chest X-ray PA and Lateral, Chest CT, Echocardiogram-transthoracic (TTE), 12 lead
echocardiogram (ECG), Arterial blood gases (ABG), CMP/Chem13, Lymph node biopsy, Tuberculin skin
test
Problem Statement:
( Demographic description – chief complaint – Hx and PE key findings – risk factors )
Polly Pocket is a 18yo girl brought in by her mother with complaint of shortness of breath with
accompanied back pain. She states that she has respiratory distress even at rest that has been increasing
in severity over the last 2 hours and had insidiously started over 2 weeks, she reports 10/10 sharp deep
back pain in midthoracic region that also started 2 weeks ago, along with this she has lost 10 pounds
over the past month. PE shows L-supraclavicular lymph node 2cm enlarged with fullness above Lclavicle, Trachea seems deviated, chest inspection shows diminished respiratory rise on left side – lung
auscultation shows absent breath sounds in LLL and diminished sounds in LUL. PMI is displaced towards
the sternum and CVA tenderness is absent. PMH and FH are unremarkable.
CC: Polly Pocket is a 18yo girl brought in by her mother with complaint of shortness of breath with
accompanied back pain
HPI: She states that she has respiratory distress even at rest that has been increasing in severity over
the last 2 hours and had insidiously started over 2 weeks, she reports 10/10 sharp deep back pain in
midthoracic region that also started 2 weeks ago, along with this she has lost 10 pounds over the past
month with night sweats.
Meds: Prednisone for suspected Fibromyalgia 10 days ago. Acetaminophen and ibuprofen for pain
PMH: noncontributory
FH: unremarkable
SH: Unremarkable
ROS: Only positive findings are seen in HPI
Physical Exam:
VS: Pulse – 94; BP – 120/80 RR – 34; T – 98.6F; SpO2 – 94%
Neck: Suspicious for tracheal deviation
Chest: Diminished respiratory rise on left (vs. right) on inspiration, auscultation shows no breath sounds
in Left lower lung and diminished breath sounds in left upper lung.
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Version | 2021 |
Category | Exam (elaborations) |
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Language | english |
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