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