Pediatricdiagnosiscases.

The Best WritersDiagnosis: ConjunctivitisChief complaint: (State the patient’s complaint in the first person)“I have itching in my right eye”HPI: In no more paragraph, indicate the patient’s situation include: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatment:Example: 8 days ago(O) my left eye (L) is itching (C), the itching has been progressive (D) and worsens with heat(AF), but the cold relieves the discomfort a little (RF), I took acetaminophen but it did not improve (T)ImmunizationIndicate the last vaccination date applied according to age. Include Covid vaccineROSEyes:Reports Itching in right eye 8 days agoOBJECTIVEPatient data must match ageAge: 16 YOWeight 65kgBMI 21.5Height 160cmTemp 97.7 FBP 120/61Pulse 100 beats per minResp 32 breaths per minEyes:Indicate the physical and clinical findings of the patient compatible with the pathology. It is not allowed to repeat the patient’s complaint.All terminology must be medical and indicate clear symptoms of the indicated diagnosis.Right eye erythematous with mucopurulent discharge; edematous right eyelid; normal visual acuity; cornea clear bilaterally, and extraocular eye movements intact. No nystagmus was notedWords without meanings are not allowed. Use only sentencesPharmacological treatment:Include, dose, how often and for how longMinimum 2 drug per tableErythromycin 0.5% ointment applies BID in right eye for 5 days.Tylenol 500 mg, 1 tablet every 6-8 hours or Ibuprofen 200 mg, 200 mg liquid gel caps every 6-8 for pain or fever.Diagnosis 1H65.11 ACUTE AND SUBACUTE ALLERGIC OTITIS MEDIAChief complaint:“XXXXXX”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSEarOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minEarPharmacological treatment:Diagnosis 2H10.13 ACUTE ATOPIC CONJUNCTIVITIS, BILATERALChief complaint:HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSEyesOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minEyesPharmacological treatment:Diagnosis 3J21.9 ACUTE BRONCHIOLITIS, UNSPECIFIEDChief complaint:HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSRespiratoryOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minRespiratoryPharmacological treatment:Diagnosis 4K29.00 ACUTE GASTRITIS WITHOUT BLEEDINGChief complaint:HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSAbdominalOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minAbdominalPharmacological treatment:Diagnosis 5J01.00 ACUTE MAXILLARY SINUSITIS, UNSPECIFIEDChief complaint:HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSRespiratoryMouthNoseOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minRespiratoryMouthNosePharmacological treatment:Diagnosis 6J80 ACUTE RESPIRATORY DISTRESS SYNDROMEChief complaintHPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSRespiratoryPulmonaryOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minRespiratoryPulmonaryPharmacological treatment:Diagnosis 7H66.0 ACUTE SUPPURATIVE OTITIS MEDIAChief complaintHPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSEarOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minEarPharmacological treatment:Diagnosis 8J30.81 ALLERGIC RHINITIS DUE TO ANIMAL (CAT) (DOG) HAIR AND DANDERChief complaint“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSSkinOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minSkinPharmacological treatment:Diagnosis 9Z91.011 ALLERGY TO MILK PRODUCTSChief complaint“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSSkinGastrointestinalOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minSkinGastrointestinalPharmacological treatment:Diagnosis 10D64.9 ANEMIA, UNSPECIFIEDChief complaint“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSSkinEyesOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minSkinEyesPharmacological treatment:Diagnosis 11W54.0 BITTEN BY DOGChief complaint:“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSSkinMusculoskeletalOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minSkinMusculoskeletalPharmacological treatment:Diagnosis 12J40 BRONCHITIS, NOT SPECIFIED AS ACUTE OR CHRONICChief complain“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSNosePulmonaryOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minNosePulmonaryPharmacological treatment:Diagnosis 13R01.1 CARDIAC MURMUR, UNSPECIFIEDChief complaint“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSCardiologyPulmonaryOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minCardiologyPulmonaryPharmacological treatment:Diagnosis 14L03.01 CELLULITIS OF FINGERChief complaint“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSSkinOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minSkinPharmacological treatment:Diagnosis 15M54.2 CERVICALGIAChief complaint“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSMusculoskeletalOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minMusculoskeletalPharmacological treatment:Diagnosis 16A74.0 CHLAMYDIAL CONJUNCTIVITISChief complaint“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSSkinEyesOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minSkinEyesPharmacological treatment:Diagnosis 17Q35.9 CLEFT PALATE, UNSPECIFIEDChief complaint“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSMouthOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minMouthPharmacological treatment:Diagnosis 18R10.83 COLICChief complaint“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSGastrointestinalOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minGastrointestinalPharmacological treatment:Diagnosis 19K59.0 CONSTIPATIONChief complaint“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSGastrointestinalOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minGastrointestinalPharmacological treatment:Diagnosis 20J45.991 COUGH VARIANT ASTHMAChief complaint“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSPulmonaryOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minPulmonaryPharmacological treatment:Diagnosis 21E30.0 DELAYED PUBERTYChief complaint“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSGenitourinaryEndocrineOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minGenitourinaryEndocrinePharmacological treatment:Diagnosis 22R19.7 DIARRHEA, UNSPECIFIEDChief complaint“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSGastrointestinalOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minGastrointestinalPharmacological treatment:Diagnosis 23J39.9 DISEASE OF UPPER RESPIRATORY TRACT, UNSPECIFIEDChief complaint“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSPulmonaryOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minPulmonaryPharmacological treatment:Diagnosis 24R14.3 FLATULENCEChief complaint“ ”HPI: Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors and treatmentImmunizationROSGastrointestinalOBJECTIVEAge: XX YO, Weight XX Kg, BMI XX , Height XXcm, Temp XX F BP XX/XX Pulse XX beats per minResp XX breaths per minGastrointestinalPharmacological treatment: