NR 602 Week 5 iHuman Notes

$25.00

Institution	Chamberlain
Contributor	Sharoon

Description

Past medical hx:

Down’s syndrome

CHF as infant (resolved after heart surgery) Congenital heart defect (ASD)

Delayed learning & growth (doesn't say many new words yet, doesn't pick up on things quickly)

Hospitalized after surgery as infant for ASD repair, multiple ER visits “b/c he’s so clumsy & always banging himself up”

NKA

No medications (Rx or OTC) (used to take medication for heart problems, but doesn't need them anymore after heart defect repair)

UTD immunizations (except overdue for 2 year scheduled immunizations) Has not seen a dentist

Unknown when last physical exam

Family hx:

Social hx:

Tobacco: exposure to secondhand smoke in home (mother & her boyfriend both smoke in the home, but not in the same room)

Diet: normally has good appetite per mother

Living situation/housing: lives with mother & 2 siblings (5 y.o. & 6 month old), mother’s boyfriend occasionally stays over, pt’s father is not involved or present in pt’s life. Neighbors & boyfriend help w/childcare (mother’s can’t afford daycare—works as a cashier in a retail shop/high school education)

History:

HPI: Mother states progressively worsening abdominal pain x 2 days w/fussiness, decreased appetite & PO fluid intake, vomiting x 1, withdrawn, & decreased urine output & BM after fall off bed during a nap per mother's boyfriend.

General: Increased fussiness, withdrawn, decreased energy. HEENT/neck: Denies.

Cardiovascular: Hx CHF in past before heart surgery as infant to repair "hole in heart", no issues since then.

Respiratory: Increased respiratory rate.

GI: Abd pain, distention, tenderness, bruising w/decreased appetite & PO fluid intake. No BM noted since symptoms began. Denies any diarrhea. 1 episode of vomiting last night.

GU: Decreased urine output w/dark & strong smelling urine.

Musculoskeletal: "Clumsy, always falling down, tripping over & bumping into things." Neurologic: Decreased energy & withdrawn, not acting like normal self.

Skin: Bruising to abdomen, skin sweaty & clammy. Psychiatric: Withdrawn, fussiness, change in behavior. Endocrine: Increased sweating & change in appetite. Hematologic: Bruises easily & often.

Allergic: Denies any food or environmental allergies. +exposure to secondhand cigarette smoke in the home.......... Continue