NRNP 6541 WEEK 7 iHuman
SAMANTHA GRAVES
NRNP
6541C
Primary Care of
Adole... [Show More] scents & Children
Patient Information: SG, 18-month-old, African-American, Female
Subjective:
CC (chief complaint): Vomiting and diarrhea
HPI: Samantha is an 18-month-old female who presents today with her mother with complaints ofvomiting and diarrhea times 2 days. Sister recently had similar symptoms. Her mother reports that Samantha has vomited 4-5 times daily for the past two days and had 3-4 episodes of liquid diarrhea daily for the past two days. Vomit is liquid with some partially digested food. Diarrhea is liquid. Denies coffee-ground emesis or blood in stool or vomit. No fever, cough, decreased activity. The mother does report concerns over decreased appetite. Had been taking Pedialyte and tolerating small amounts of Pedialyte and milk. Physical exam without signs of dehydration, abdominal pain, or rebound tenderness.
Current meds: None
Allergies: NKDA
Pertinent PMHx: Samantha is in general good health. No pertinent past medical history noted. She is up to date on immunizations and has regular check-ups. She has met all developmental milestones for her age and is at the 75th percentile for height and weight.
Immunizations:
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, due today
Social hex: Lives in an apartment with her parents and 4-year-old sister. Her mother is a teacherand her father is an engineer.
Fam Hex:
1. Mother, 32-years-old, healthy
2. Father, 36-years-old, healthy
ROS:
GENERAL: Alert, active.
HEENT: No runny nose, eye or ear discharge. No conjunctivitis.
SKIN: No rashes, bruising or petechiae.
CARDIOVASCULAR: No history of murmurs, gallops or rubs. RESPIRATORY: Denies any SOB, cough, wheezing or difficulty breathing. GASTROINTESTINAL: Nausea, vomiting and diarrhea x 2 days. Decreased appetite.
GENITOURINARY: Urinates normally. No history of UTI’s. 6-7 wet diapers a day.
NEUROLOGICAL: No history of seizures or headaches.
MUSCULOSKELETAL: No recent trauma, weakness, or limping.
LYMPHATICS: Denies any lymph node enlargement.
HEMATOLOGIC: Denies anemia, unexplained bruising or bleeding.
PSYCHIATRIC: Denies any abnormal mental health issues, happy child per mother. ENDOCRINOLOGIC: Denies excessive sweating, thirst, or urination. Denies heat or cold intolerance.
ALLERGIES: Denies frequent or re-occurring infections or hives. Up to date on immunizations. [Show Less]