NR 602 Week 7 iHuman Case 5 - Javier Flores

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Institution	NR 602 Primary Care of the Childbearing and Childrearing Family
Contributor	Racheal Ofori

Description

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3 months ago visit

Reason: well child check

Hx of present illness: 13-18 m milestone

MOTOR: walks independently, squats to pick up a toy, stacks two objects.

SENSORY: helps with getting dressed/undressed. Has regular sleep schedule. Eats an increasing variety of foods.

COMMUNICATION: use 5-10 words. Combines sounds and gestures. Imitates simple words and actions. Consistently follows simple directions. Shows interest in pictures. Can ID 1-2 body parts when named. Understands 50 words.

FEEDING: increases variety of coarsly chopped table foods. Holds and drinks from cup. ROS

GU: wears diapers, 4-5 wet diapers a day. GI: has soft formed stools twice daily.

Allg/Immun: Up to date for all immunizations until 1 yr of age. PMH: none

Hosp/Surg: Gestational age at birth (37 weeks). No past hospitalizations or surgeries MEDS: none

Allg: NKNA

PREVE: fitness: active/runs/walks. Nutrition: breastfed until age 1. Eats solid foods; drinks from sippy cup.

IMMUN:

Birth: Hep B

2 Months: DTap, IPV, HIB, PCV13, Rotavirus, Hep B 4 Months: DTap, IPV, HIB, PCV13, Rotavirus

6 Months: DTap, IPV, HIB, PCV13, Rotavirus, Hep B, Influenza 1st dose 7 Months: Influenza 2nd dose

12 Months: MMR, Varicella, Hep A 1st dose 15 Months: DTap, HIB, PCV13

18 Months: Hep A 2nd dose due at this visit NOT IN THIS IHUMAN Family Hx:

Father: 35 in good health. Mother: 33 in good health. Siblings: 5 y/o brother in good health but has seasonal allergies. Other familial diseases none.

SOCIAL: Lives at home with mother, father and brother.................... Continue