CC: 2 y/o M/F
Chief complaint is a short 1-2 statement or word
phrasefrom patient and should be listed in “quotes”
Mother’s
... [Show More] statement
“2 days ago, she started with a runny
nose andcough”
PMHx child/adult
illness/hospitalizations/immunizations
No hospitalizations, trauma, or other
injuriesImmunizations: Mother states
she has not received flu vaccine this
season but update on all
recommended vaccinations.
Onset: Cough and runny nose started
3 daysago and fever for the past 2
days
Location: NA
Duration: About 3 days and
symptoms havepersisted
Character: Cough is unproductive
HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
Emma Ryan is a 2-year-old girl who presented to the clinic with her
mother with a complaint of runny nose and a cough that started 3 days
ago and feverthat started 2 days ago. She tolerates milk well, but her
appetite is reduced with no change in the number of wet diapers. The
mother reports she did notreceive the flu vaccine this season; she is
exposed to secondhand smoking at home and exposure to sick children
at daycare.
Treatments: Tylenol every 4 hours for fever
Significance: Fever in toddlers is significant and fussiness and loss of
appetite isindicative of discomfort
SurgHx type/when/why/complications
No history of surgery
FamHx
Grandparents (if known)/Parents/siblings/children
Mother-age 31-No history of medical problems Father-age 35 with
history ofmild intermittent
Aggravating/alleviating factors: No
aggravating or alleviating noticed or
reportedby mom
Related symptoms: Fussiness and
reduced appetite. Crying could be an
indication of pain of discomfort (FLACC
score of at least 2)
asthma
Brother-age 5 healthy
SHx
Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships
Exposed to secondhand smoking by both parents in the home
Reproductive Hx Female: Age of menarche/menstruation cycle duration/gravida para
status/Childbirth hx/sexual hx and concerns/LMP/menopause
:
Breast/cervical screening (if any) Male:
Sexual hx and concerns/issues with
fertility (if any)/Testicularor prostate
screening (if applicable) Screening for
STI’s (if applicable)
Toddler, no schedule history
Allergies (Food, Drug,
Environmental, etc.)
No known allergies
List of Medications/supplements (prescription, OTC, complementary
alternative therapies)
Tylenol OTC for fever
Review of Systems: (ROS) Use this column to
document the ROS below. General: Crying
HEENT: Runny nose
Pulmonary: Nonproductive cough
CV: No shortness of breath GI: Wears
diapers. She has about 1-2 stool diapers
per day, decreased appetite and no
vomiting
Decrease in appetite
GU: No change in number of wet diapers
From the ROS: list/highlight the current
symptoms/complaints to generate a list of
pertinent “reported or denied” symptoms
below:
Pertinent Positive ROS: Cough, runny nose,
decreased appetite
Pertinent Negative ROS: No signs of shortness
of breath, No changes in voiding and bowel
movement, no vomiting [Show Less]