I-Human Case Study
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I-Human Case Study
Patient Information
Name –
... [Show More] T.C.
Age – 2 years.
Gender – female.
Subjective
Chief Complaint: “Runny nose, cough, and fever.”
HPI: The 2-year-old female was brought to the clinic by her mother with complaints of runny
nose, cough, and fever. She reported that the disorder started three ago, but the fever began a day
ago. She reports that the disorder is characterized by fussiness and decreased appetite. She
reports administering Tylenol every four, but the fever returned after about four hours.
Past Medical History: She denies hospitalizations. She says that the child met all developmental
milestones and is without disability.
Allergies: No known allergies.
Past Surgical History: No surgical history.
Medications: Tylenol
Family History: No family history of the present disorder.
Social History: Both parents are smokers. The child is in daycare, where several children are
sick.
Health maintenance: The child missed this season’s flu shot.
Review of Systems:
i. General: The child is generally fussy and crying.
ii. HEENT/neck: Runny nose
iii. Lungs: Reports a cough.
iv. Cardiovascular: Denies palpitations and pain.
v. G.I.: Reports loss of appetite.
vi. Pelvic/GU: Denies changes in toileting.
vii. Neuro: Reports fever that comes and goes.
viii. Endocrine: Denies weight fluctuations.
ix. Musculoskeletal: Denies changes in activity.
x. GU: Reports regular wetting of diapers.
xi. Derm: Denies integumentary changes.
xii. LMP: Denies swelling of lymph nodes.
xiii. Sleep/Rest: She reports staying up all night.
Physical Exam
i. General: The patient is fussy and crying.
ii. Vitals:
BP- 100/60, temp – 101.0 F, HR - 85, RR - 20, WT- 27 lb, H – 86 cm , BMI- 16.4
iii. HEENT/neck: Rhinorrhea and pharynx with erythema and exudate observed. Bilateral
severe bulging of the tympanic membrane was also observed.
iv. Chest and lungs: Cough.
v. Skin: warm, dry, normal turgor, and no lesion.
vi. Lymphatic: No pathologically enlarged lymph nodes.
vii. Cardiovascular: capillary refill time less than 3 seconds.
viii. Abdomen: Assessment reveals the absence of mass, rebound, or [Show Less]