N602 week 7 ihuman child Primary Diagnosis: Pelvic inflammatory Disease. Latest 2023.3 months ago visit
Reason: well child check
Hx of present illness:
... [Show More] 13-18 m milestone
MOTOR: walks independently, squats to pick up a toy, stacks two 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:
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
PMH
4. Does he have any allergies?
None that we know of [Show Less]