2 month-old Caucasian female presents with her mother with complaints of “congestion and runny that began three days ago”. Mother states it is
... [Show More] constant and is worse at night. States the congestion is a 6/10 and interferes with nursing and sleeping. She states she has not given any medications to treat her symptoms. States that she has been using a humidifier at home, but it has been ineffective in helping with the congestion. Her runny nose began 3 days ago and it runs constantly and is yellow/clear and loose. Mother states child has developed a slight cough this morning. Mother reports no other associated symptoms. Mother denies any fever, vomiting, diarrhea. Mother states that child stays home with her, and her 2 bothers. No one in the household is sick, but her brothers just started back at school. Exclusively breastfeeding. 7-8 wet diapers/day, clear-yellow in color. 5-6 bm a day, yellow and seedy in consistency. Mother states baby sleeps in a crib in her bedroom. States she usually sleeps 4-5 hours before waking but has been sleeping only 2-3 hours at a time for the last three days. Mother states they have one dog in the household. Denies being around smoke.
PMH Medications: None
: Allergies: NKDA
Birth history: spontaneous vaginal delivery at 40 weeks gestational age,
Mother was GBS negative at delivery
Medical: Umbilical hernia
Immunizations: UTD, Heb B given in Hospital after birth
PSH None reported
FH Mother – 32 – Living - No medical history Father – 35 – Living – HTN, GERD
Brother – 8 – Living – No medical history
Brother– 6 – Living – No medical history
Maternal grandmother – 56 – Living – HTN
Maternal grandfather – 55 – Living – HTN
Paternal grandmother – 61 – Living – Breast cancer (in remission)
Paternal grandmother – 62 – Living – No known medical history
SH Lives at home with mother and father who are married and live in single family household. Father works M-F job, 8-5 as an accountant. Has two older brothers. Mother stays at home and baby stays home with mother. Brothers are in school 5 days a week. Rides in rear facing car seat. Family has a golden retriever who is healthy and lives in the house with them. Patient’s home is supplied with city water, adequate sewage/waste removal systems are in place. [Show Less]