*NURSING > CASE STUDY > NR 602 Week 7 iHuman Case 5 Michael Martinez REASON FOR ENCOUNTER COUGH, History, HEENT, Problem Sta (All)

NR 602 Week 7 iHuman Case 5 Michael Martinez REASON FOR ENCOUNTER COUGH, History, HEENT, Problem Statement, Diagnostics, Result, Interpretation

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Week 7 iHuman Case 5 Reason for Encounter: Cough History of Present Illness: Pt is an 18 month old child here with his mother who states that he has had a runny nose for the past 5 days, and had sta... rted coughing for the past 2 days. He has been having fevers of 102*F. Being active makes his cough worse. Mother has only given him Tylenol 2-3 times for his fever/symptoms. His appetite has been less than normal but is drinking normally. He is exposed to secondhand smoke at home from his father. Mother states that he has been in contact with sick kids at his daycare. He has no known allergies. Review of Systems General No fever, alert, active. Integumentary / Breast Deferred HEENT / Neck Pt has a runny nose that started 5 days and a cough that started 2 days ago. Cardiovascular Cough and runny nose makes it difficult for him to breathe Respiratory Pt has a cough and runny nose that started 2 days ago. Mother states cough has been productive. Gastrointestinal Has about 1-2 stool diapers per day. Eating less than normal for the past few days, but drinking normally. No problems with nausea, vomiting, constipation, diarrhea, coffee grounds in her vomit, dark tarry stool, bright red blood in her bowel movements. Genitourinary Has 4-5 wet diapers per day. Musculoskeletal Deferred Allergic NKA. Up to date on all immunizations Endocrine Deferred Hematologic / Lymphatic Deferred Neurologic Deferred Psychiatric Deferred Past Medical History PMH: None Hospitalizations/Surgeries: Gestational age at birth (37 weeks). No past hospitalizations for surgeries Preventive Health: Fitness: Active, runs, walks. Nutrition: Breastfed until age 1. Eats solid foods; drinks from a sippy cup. Medications: Tylenol Allergies: NKDA................... Continue [Show More]

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