NR 602 Week 7 iHuman Case 5 - Pt is an 18 month old child

  • NR 602 Week 7 iHuman Case 5 - Pt is an 18 month old child
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Institution NR 602 Primary Care of the Childbearing and Childrearing Family
Contributor Racheal Ofori

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Reason for Encounter: Cough

History of Present Illness: Pt is an 18 month old child here with his mother who states that he has had a runny nose for the past 5 days, and had started coughing for the past 2 days. He has been having fevers of 102*F. Being active makes his cough worse. Mother has only given him Tylenol 2-3 times for his fever/symptoms. His appetite has been less than normal but is drinking normally. He is exposed to secondhand smoke at home from his father. Mother states that he has been in contact with sick kids at his daycare. He has no known allergies.

Review of Systems

General

No fever, alert, active.

Integumentary / Breast

Deferred

HEENT / Neck

Pt has a runny nose that started 5 days and a cough that started 2 days ago.

Cardiovascular

Cough and runny nose makes it difficult for him to breathe

Respiratory

Pt has a cough and runny nose that started 2 days ago. Mother states cough has been productive.

Gastrointestinal

Has about 1-2 stool diapers per day. Eating less than normal for the past few days, but drinking normally. 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: Gestational age at birth (37 weeks). No past hospitalizations for surgeries

Preventive Health: Fitness: Active, runs, walks. Nutrition: Breastfed until age 1. Eats solid foods; drinks from a sippy cup.

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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