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NR 511MMiller. Week3 SOAP.docx

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NR 511MMiller. Week3 SOAP.docx Riley 18 months, male Subjective Chief complaint: fever and rash History of present illness (HPI): O: Onset-three days ago and is of normal levels in the morning th ... en gets as high as 100 to 101 degrees in the afternoons. L: Location— developed a red, diffuse rash to the torso and abdomen D: Duration-three days C: Characteristics/Associated symptoms- clear rhinorrhea in the last 24 hours. Rash that does not itch and a barking cough in the last day. Not eating, not playing, minimal drinking. A: Aggravating factors-not discussed R: relieving factors- temporary relief of coughing after robitussin for the cough, and tylenlol for fever T: Treatments- Mother has stopped the Zyrtec. She is giving Robitussin cough and cold at 2.5 ml last night and this morning. Liquid Tylenol 7.5 ml last night and this morning. S: Severity- Mother is very concerned about the level of the fever and the fact that after 3 days he is not improving. Past Medical History- Born at 34 weeks gestation via cesarean section, weight. 5 pounds 1 ounce. The mother developed preeclampsia and gestational diabetes. The mother quit smoking when she found out she was pregnant. Riley has allergies per mother and sometimes takes Cetrizine syrup 2.5ml once daily, PRN congestion, and a children’s chewable multivitamin daily. immunization history- Birth – Hep B, 2 months – DTaP, COMVAX, PCV13, IPV, 4 months - DTaP, COMVAX, PCV13, IPV, 6 months – DtaP, PCV 13, IPV, Hep B Family History- They are maternal and paternal smokers. The mother has been one since age 22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no diseases reported in either parent. Kayla has a history with gestational diabetes. Mary has a history of hyperlipidemia, Type 2 DM, and Hypertension. They are Latin American in descent, emigrated from Cuba in the 1970s. Tom has a history of hypertension, hyperlipidemia, and an MI with stenting 2 years ago. The mother has two siblings; one who died in an MVA 5 years ago at the age of 18 a younger brother, and an older sister who is 42 and lives in a large urban city in the Midwest with her family, and she is in good health but also had PCOS and difficulty conceiving. Other family members died of old age. She is unaware of paternal familial health history. Field Family: Mother: Kayla-age 37, Father: Mike-age 39, Daughter: Lily-age 15, Daughter: Jo- age 5, Son: Riley-age 13 months. Maternal Grandmother: Mary-age 55, Paternal Grandfather: Tom-age 62 [Show More]

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