Nick Roberts

2-year-old male

2’10” 27 lbs. (12.3 kg)

Reason for encounter: Runny nose, cough, fever Observations: Patient is laying on exam table.

Skin is warm and dry.

Questions:

• How can I help him today?

• Patient’s mother (Renee) reports that 2 days ago he started with a runny nose and cough. Then yesterday the daycare sent him home for a fever. He has been fussy

this morning as well and he had a fever. So now we’re on day 3 of him not being well. I was hoping to get some medication for his cough today because I’m not sure what is making him so fussy!

• Does he have any other symptoms or concerns we should discuss?

• Besides the cough, fever, runny nose, and fussiness…he has also not been eating as well. He has been drinking his milk normally, about 18 ounces of while milk

per day. But his appetite for food has been a little decreased. He seems to be a little picky the last couple of days.

• How high is his fever?

• The highest it has been at home is 101F. The daycare sent him home yesterday for a fever of 100.9F.

• What treatments has he had for his fever?

• Tylenol every 4 hours when he has a fever. It goes away with Tylenol but returns about 4 hours later.

• Does his fever keep him from sleeping?

• He woke up several times last night crying with a fever.

• When did his cough start?

• 2 days ago

• Does anything make his cough better or worse?

• Not really.

• Is he coughing up any sputum?

• No.

• Has there been any change in his cough over time?

• It hasn’t really changed.

• What treatments has he had for his cough?

• Nothing

• When did his runny nose/nasal congestion start?

• Two days ago.

• Does anything make his runny nose/nasal congestion better or worse?

• Not really.

• What treatments has he had for his runny nose/nasal congestion?

• Nothing.

• Does he have any nausea and vomiting?

• No.

• Does he have a sore throat?

• I’m not sure, he cannot tell me.

• Does he have any allergies?

• No.

• Is he taking any over the counter or herbal medications?

• Not normally.

• Is he taking any prescription medications?

• Nope.

• Has he had a flu shot this year?

• No, it made him sick last year so we decided not to get it for him this year because I just cannot afford to miss any more days of work.

• How many wet diapers?

• Several. I don’t usually count. That’s been the same.

• How many stool diapers?

• Usually about one or two. That’s been the same.

• Have you noticed your child pulling on his ear?

• No

• Does he have discharge or bleeding from his ears?

• Nope.

• Does he have a rash?

• Nope.

• Has he had any contact with other sick people?

• He is in daycare and several children have been sick lately.

• Does he have pain anywhere?

• I think he does because he has been fussy. He cannot tell me if he has pain anywhere.

Patient’s mother reports that his overall health has been pretty good. He has never been hospitalized. He has met all his developmental milestones and has been doing great in terms of his weight and height. I’ve been blessed with a healthy child so far! ……….. Continue