Chief Complaint 5
Student Name: Adolfo Acevedo Mendez
Student Number: 21928769
PENN FOSTER MEDICAL CENTER
Emergency Department Note
SUMMERS, JENNIFER
July 01, 2014
CHIEF COMPLAINT
Congestion and poor feeding
HISTORY OF PRESENT ILLNESS
This is a 3-month-old little girl who comes in with her mother. Her mom says that she works overnight and the baby stays with the grandmother. Last night, apparently, the baby starting around 9 o'clock was not interested in feeding. Seems very congested, had a cough, and overnight did not sleep well. This morning her grandmother said the baby was fuzzy all night long and was not feeding and mom noted the diaper was dry and so she brought the baby to the emergency department. There is some question about that diaper remaining dry from the past 12 hours. No vomiting, no diarrhea, no fever, and no other new concern. The child 3-month-old with normal development and normal growth.
PAST MEDICAL HISTORY
No other medical problems. No irregular medication. No drug allergy.
SOCIAL HISTORY
She lives at home with the mother and is helped with the grandmother.
REVIEW OF SYSTEMS
On exam, the little girl is awake and alert. Makes good eyes contact and is breathing regularly.
PHYSICAL EXAMINATION
VITAL SIGNS: Temperature 98, pulse 132,Respiratory rate 40,pulse oxymetry 97% on room air.
GENERAL: Normocephalic atraumatic. Fontanelle is flat.
HEENT: Pupils are equal round reactive to light. Scleras are clear. Oropharynx is unremarkable. No lesions or exudates. Tympanic membranes were clear bilaterally.
NECK: Supple.
CHEST:Lungs were clear to auscultation bilaterally. No wheeze.
HEART:Heart rate is regular rate and rhythm. Normal S1,S2.
ABDOMEN:No apparent splenomegaly.
EXTREMITIES: Neurovascularly intact without rash, edema or tender joints. Normal tone. Normal perineum.
SUMMERS, JENNIFER
July 01, 2014
Page 2
HOSPITAL COURSE
After my evaluation, the child did not appear significantly dehydrated. Was awake, and alert, and was afebrile. We
Student Number: 21928769
PENN FOSTER MEDICAL CENTER
Emergency Department Note
SUMMERS, JENNIFER
July 01, 2014
CHIEF COMPLAINT
Congestion and poor feeding
HISTORY OF PRESENT ILLNESS
This is a 3-month-old little girl who comes in with her mother. Her mom says that she works overnight and the baby stays with the grandmother. Last night, apparently, the baby starting around 9 o'clock was not interested in feeding. Seems very congested, had a cough, and overnight did not sleep well. This morning her grandmother said the baby was fuzzy all night long and was not feeding and mom noted the diaper was dry and so she brought the baby to the emergency department. There is some question about that diaper remaining dry from the past 12 hours. No vomiting, no diarrhea, no fever, and no other new concern. The child 3-month-old with normal development and normal growth.
PAST MEDICAL HISTORY
No other medical problems. No irregular medication. No drug allergy.
SOCIAL HISTORY
She lives at home with the mother and is helped with the grandmother.
REVIEW OF SYSTEMS
On exam, the little girl is awake and alert. Makes good eyes contact and is breathing regularly.
PHYSICAL EXAMINATION
VITAL SIGNS: Temperature 98, pulse 132,Respiratory rate 40,pulse oxymetry 97% on room air.
GENERAL: Normocephalic atraumatic. Fontanelle is flat.
HEENT: Pupils are equal round reactive to light. Scleras are clear. Oropharynx is unremarkable. No lesions or exudates. Tympanic membranes were clear bilaterally.
NECK: Supple.
CHEST:Lungs were clear to auscultation bilaterally. No wheeze.
HEART:Heart rate is regular rate and rhythm. Normal S1,S2.
ABDOMEN:No apparent splenomegaly.
EXTREMITIES: Neurovascularly intact without rash, edema or tender joints. Normal tone. Normal perineum.
SUMMERS, JENNIFER
July 01, 2014
Page 2
HOSPITAL COURSE
After my evaluation, the child did not appear significantly dehydrated. Was awake, and alert, and was afebrile. We