3 months ago visit
Reason: well child check
Hx of present illness: 13-18 m milestone
MOTOR: walks independently, squats to pick up a toy, stacks two
... [Show More] objects.
SENSORY: helps with getting dressed/undressed. Has regular sleep schedule. Eats an increasing
variety of foods.
COMMUNICATION: use 5-10 words. Combines sounds and gestures. Imitates simple words
and actions. Consistently follows simple directions. Shows interest in pictures. Can ID 1-2 body
parts when named. Understands 50 words.
FEEDING: increases variety of coarsly chopped table foods. Holds and drinks from cup.
ROS
GU: wears diapers, 4-5 wet diapers a day.
GI: has soft formed stools twice daily.
Allg/Immun: Up to date for all immunizations until 1 yr of age.
PMH: none
Hosp/Surg: Gestational age at birth (37 weeks). No past hospitalizations or surgeries
MEDS: none
Allg: NKNA
PREVE: fitness: active/runs/walks. Nutrition: breastfed until age 1. Eats solid foods; drinks from
sippy cup.
IMMUN:
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
18 Months: Hep A 2nd dose due at this visit NOT IN THIS IHUMAN
Family Hx:
Ihuman week 7 Javier Flores Child Case Study
Father: 35 in good health. Mother: 33 in good health. Siblings: 5 y/o brother in good health but
has seasonal allergies. Other familial diseases none.
SOCIAL: Lives at home with mother, father and brother.
THIS VISIT!!!
Javier Flores
18 months
2’11 (89 cm)
28.0 lb (12.7 kg)
BMI 16.1
A&Ox4
38.9 (102.0) oral temp
110 bpm, rhythm: regular, strength: Normal
BP Left: 100/60, Right: 100/60, Assessment: normal, Pulse pressure: normal
RR: 40 bpm, Rhythm: regular, Effort: labored
Sp02: 92%
Reason for encounter: Cough
SKIN: Warm and dry
History:
1. How can I help him today?
He has been coughing and also has a fever. He seems to be getting sicker, so I thought I should
have someone look at him.
2. Does he have any other symptoms or concerns we should discuss?
Yes. He has a runny nose and difficulty breathing, too. He hasn’t been his usual self since this
started.
HPI: PEDS
3. How many wet diapers does your child make per day?
About 4-5
Ihuman week 7 Javier Flores Child Case Study
PMH
4. Does he have any allergies?
None that we know of
5. Is he taking any prescription medications?
No, nothing prescription. I’m thinking he needs something though
HPI: Cough
6. When did his cough start?
Started 2 night ago
7. Does anything make the cough better or worse? [Show Less]