NR 602 Week 6 iHuman Case 4 - Kecia Young
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| Term | Year 2022 |
| Institution | NR 602 Primary Care of the Childbearing and Childrearing Family |
| Contributor | Racheal Ofori |
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Reason for Encounter: Rapid spreading rash that started this morning
History of Present Illness: Pt is a 2 y/o female here with her mother. Mother brought her into the clinic because she developed a rash that started this morning on her abdomen, and has now rapidly spread to her arms and legs. No PMH or known allergies. Three days ago the pt developed a cough, runny nose, and fever. Yesterday had a fever of 103*F, that has now been resolved since last night. Cough and runny nose are still persistent. Pt was only given tylenol. Mother denies pt being in contact with anyone else with similar symptoms. Mother denies any changes in her appetite, nausea, vomiting, or diarrhea. Mother states pt has been eating/drinking well, has 2 stool diapers and 4-5 wet diapers per day.
Review of Systems
General | No fever, alert, active. |
Integumentary / Breast | Rapid rash on the abdomen that started this morning and has now spread to her arms and legs. Mother denies any itching/pain associated with the rash. |
HEENT / Neck | Pt has a cough and runny nose that started 3 days ago. |
Cardiovascular | No shortness of breath |
Respiratory | Pt has a cough and runny nose that started 3 days ago. No sputum production |
Gastrointestinal | Has about 2 stool diapers per day. Eating/drinking well. No changes in her appetite. No problems with nausea, vomiting, constipation, diarrhea, coffee grounds in her vomit, dark tarry stool, bright red blood in her bowel movements. |
Genitourinary | Has 4-5 wet diapers per day. |
Musculoskeletal | Deferred |
Allergic | NKA. Up to date on all immunizations |
Endocrine | Deferred |
Hematologic / Lymphatic | Deferred |
Neurologic | Deferred |
Psychiatric | Deferred |
Past Medical History PMH: None
Hospitalizations/Surgeries: She was born full term at 38 weeks GA, born via NSVD. No complications during delivery or after birth
Preventive Health: Has been meeting all developmental milestones. Growing and developing well.
Medications: Tylenol
Allergies: NKDA ................... Continue
| Instituition / Term | |
| Term | Year 2022 |
| Institution | NR 602 Primary Care of the Childbearing and Childrearing Family |
| Contributor | Racheal Ofori |
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