Patient Information: AB, 5-year-old, African-American, male
Subjective:
CC (chief complaint): bottom itches
HPI: Adam is a 5-year-old African-American
... [Show More] male who presents to the clinic with his mother
complaining that his bottom itches. He has a history of chronic constipation. He is currently only
having 1-2 BM per week. When he is feeling constipated his mother increases his fiber and water
intake, as well as gives him Miralax which helps, but they have not tried at this time. His mother
notes redness and scratch marks around his rectum. Adam denies any abdominal pain or diarrhea.
He has poor hand hygiene and bites his nails frequently.
Current meds: None
Allergies: NKA
Pertinent PMHx: Adam is in general good health. He has a history of chronic constipation that
started after the cessation of breast feeding and worsened during potty training.
Immunizations:
Hepatitis B given:
at birth
at 2 months old
at 6 months old
at 12 months old
Oral rotavirus series given:
at 2 months old
at 4 months old
at 6 months old
DTaP given:
at 2 months old
at 4 months old
at 6 months old
at 15 months old
Haemophilus Influenza Type B (HiB) given:
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NURS 6541C iHuman Adam Barnes African American Male
5yrs Bottom itches Wk 2 Case Study
at 2 months old
at 4 months old
at 6 months old
at 15 months old
Pneumococcal (PCV13) given:
at 2 months old
at 4 months old
at 6 months old
at 15 months old
Polio (IPV) given on these dates:
at 2 months old
at 4 months old
at 6 months old.
MMR (measles, mumps and rubella) vaccine given:
at 12 months old
Varicella vaccine given:
at 12 months old
Hepatitis A given:
at 12 months old
at 18 months old
Developmental:
Social hx: Lives at home with his mother and father who are married and his older sister. There
is one dog in the household. Non-smoking home in a low crime area.
Fam Hx:
1. HTN (maternal grandmother and maternal grandfather)
2. CVA (maternal grandfather)
History Questions Asked:
1. How can I help you today?
2. Tell me how that makes you feel?
3. Do you have any other symptoms or concerns we should discuss?
This study source was downloaded by 100000859807096 from CourseHero.com on 02-13-2023 07:18:08 GMT -06:00
https://www.coursehero.com/file/115320962/MillerC-wk2-ihumanAdamBarnes6541Cdocx/
NURS 6541C iHuman Adam Barnes African American Male
5yrs Bottom itches Wk 2 Case Study
4. Do you have a rash?
5. Do you have any pain in your rectum?
6. Have you felt any itching around the anus?
7. Do you have pain, tenderness or uncomfortable fullness around your anus?
8. Do you have diarrhea?
9. Has anyone else you know developed these symptoms?
10. What childhood illnesses have you had?
11. Do you have any allergies?
12. Do you have any pets?
13. Are you taking any prescription medications?
14. Are you taking any over-the-counter or herbal medications?
15. Are your immunizations up to date?
16. When was your last physical?
17. Can you tell me about your diet? What do you normally eat?
18. How many bowel movements do you have a day?
19. Do you regularly use soap and water to wash your hands before each meal?
20. Do you regularly wash your hands with soap and water after using the restroom?
21. Where do you live?
22. Do you have parents, children, other family members or individuals living in your
home?
23. How can I help him tod [Show Less]