Case: 165481 Emma Ryan
Date: 02/28/2021
CC: 2 y/o M/F
Chief complaint is a short 1-2 statement or word phrase
from patient and should be listed in
... [Show More] “quotes”
Mother’s statement
“2 days ago, she started with a runny nose and
cough”
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 fever that
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 not receive the
flu vaccine this season; she is exposed to secondhand smoking at home and
exposure to sick children at daycare.
Onset: Cough and runny nose started 3 days ago and fever for the past 2 days
Location: NA
Duration: About 3 days and symptoms have persisted
Character: Cough is unproductive
Aggravating/alleviating factors: No aggravating or alleviating noticed or
reported by mom
Related symptoms: Fussiness and reduced appetite. Crying could be an
indication of pain of discomfort (FLACC score of at least 2)
Treatments: Tylenol every 4 hours for fever
Significance: Fever in toddlers is significant and fussiness and loss of appetite is
indicative of discomfort
PMHx child/adult
illness/hospitalizations/immunizations
No hospitalizations, trauma, or other injuries
Immunizations: Mother states she has not
received flu vaccine this season but update on
all recommended vaccinations.
SurgHx type/when/why/complications
No history of surgery
This study source was downloaded by 100000844708667 from CourseHero.com on 08-31-2022 00:57:55 GMT -05:00
Case: 165481 Emma Ryan
Date: 02/28/2021
FamHx
Grandparents (if known)/Parents/siblings/children
Mother-age 31-No history of medical problems
Father-age 35 with history of mild intermittent
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)/Testicular or 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
This study source was downloaded by 100000844708667 from CourseHero.com on 08-31-2022 00:57:55 GMT -05:00
Case: 165481 Emma Ryan
Date: 02/28/2021
MS: No recent trauma or injury
Heme: No sign bruising
Lymph: No complaint
Endocrine: No history of endocrine disorder
Derm: No signs of rash
Neuro: No history of Seizures
Psych: No psychological concerns
Physical Exam: (PE) Use this column to
document the PE below.
Vitals (HR/BP/RR/T/SpO2/Ht/Wt/BMI%)
HR: 85, BP 95/60, RR: 20, SPO2: 98%, Height: 2ft
2 inches, Weight: 27lbs., BMI: 16.4
General: Crying toddler
HEENT: Normocephalic, atraumatic, no
deformities, face symmetrical, Pupils normal,
reactive, ears have no discharge and appears normal,
bilateral tympanic membranes with erythema and
severe bulging, nose has no discharge or polyps,
pharynx with erythema and exudates
Neck: No visible scars or deformities or lesions
Pulm Respirations regular and unlabored, normal
lung sounds, negative for wheezing.
CV: Normal heart sounds, HR 85
GI: No guarding or rebound tenderness. Bowel
sounds present in all 4 quadrants
GU: No diaper rash
Neuro: Awake and alert
Derm: Skin turgor normal. Skin warm and dry with
no lesions
MSK: Normal bulk and tone
From the PE: list/highlight the presence or absence of objective findings to
generate a list of pertinent “(+) or (-)” symptoms below:
Pertinent Positive PE findings: Bilateral tympanic membranes with erythema and
severe bulging, pharynx with erythema and exudates
Pertinent Negative P [Show Less]