Zoey Wright – I-Human
Patient and Encounter
● Patient: Zoey Wright
● Age: 2-year-old female
● Accompanied by: Mother, who is an accurate historian
● Reason for encounter: Fever, cough, runny nose, and ear pain/tugging
● Setting: Outpatient pediatric clinic
● PMH: No current or past medical problems
● Allergies: No known allergies
● Current illness: Sick for approximately 7 days
● Exposure: Sick children at daycare
● Vaccines: Up to date except influenza and COVID vaccination
● Family history: Family history of allergies and asthma
● Social/environmental: Parents smoke inside the home; pet in home
History
General
● How can I help you today?
● When did she first become sick?
● Has she been getting better or worse?
● What symptom is bothering her the most?
● Has she had a fever?
● What was the highest temperature?
● Has she been eating and drinking normally?
● Is she producing a normal number of wet diapers?
● Has she been unusually fussy or irritable?
Ear Symptoms
● When did she start tugging at her ears?
● Is she pulling at one ear or both?
● Does she seem to be in pain?
● Has she had ear infections before?
● Has she had drainage from the ear?
● Does she seem to have difficulty hearing?
● Does lying down or sleeping make the symptoms worse?
Respiratory Symptoms
● When did the cough begin?
, ● Is the cough dry or productive?
● Is she coughing during the day or at night?
● Any wheezing?
● Any shortness of breath?
● Any difficulty breathing?
● Any noisy breathing or stridor?
● Any periods of rapid breathing?
Upper Respiratory Symptoms
● When did the runny nose begin?
● What color is the nasal drainage?
● Has the congestion improved or worsened?
● Any sore throat?
● Any difficulty swallowing?
● Any sinus/facial pain?
Associated Symptoms
● Any vomiting?
● Any diarrhea?
● Any rash?
● Any decreased urination?
● Any lethargy?
● Any seizures?
● Any neck stiffness?
Past History
● Previous ear infections?
● Previous respiratory infections?
● History of asthma?
● Any chronic medical conditions?
● Previous hospitalizations?
● Previous surgeries?
Medications/Allergies
● What medications has she received?
● Has she received acetaminophen or ibuprofen?
● How much medication was given?
● When was the last dose?
● Any prescription medications?
● Any medication allergies?
● Any food or environmental allergies?
Patient and Encounter
● Patient: Zoey Wright
● Age: 2-year-old female
● Accompanied by: Mother, who is an accurate historian
● Reason for encounter: Fever, cough, runny nose, and ear pain/tugging
● Setting: Outpatient pediatric clinic
● PMH: No current or past medical problems
● Allergies: No known allergies
● Current illness: Sick for approximately 7 days
● Exposure: Sick children at daycare
● Vaccines: Up to date except influenza and COVID vaccination
● Family history: Family history of allergies and asthma
● Social/environmental: Parents smoke inside the home; pet in home
History
General
● How can I help you today?
● When did she first become sick?
● Has she been getting better or worse?
● What symptom is bothering her the most?
● Has she had a fever?
● What was the highest temperature?
● Has she been eating and drinking normally?
● Is she producing a normal number of wet diapers?
● Has she been unusually fussy or irritable?
Ear Symptoms
● When did she start tugging at her ears?
● Is she pulling at one ear or both?
● Does she seem to be in pain?
● Has she had ear infections before?
● Has she had drainage from the ear?
● Does she seem to have difficulty hearing?
● Does lying down or sleeping make the symptoms worse?
Respiratory Symptoms
● When did the cough begin?
, ● Is the cough dry or productive?
● Is she coughing during the day or at night?
● Any wheezing?
● Any shortness of breath?
● Any difficulty breathing?
● Any noisy breathing or stridor?
● Any periods of rapid breathing?
Upper Respiratory Symptoms
● When did the runny nose begin?
● What color is the nasal drainage?
● Has the congestion improved or worsened?
● Any sore throat?
● Any difficulty swallowing?
● Any sinus/facial pain?
Associated Symptoms
● Any vomiting?
● Any diarrhea?
● Any rash?
● Any decreased urination?
● Any lethargy?
● Any seizures?
● Any neck stiffness?
Past History
● Previous ear infections?
● Previous respiratory infections?
● History of asthma?
● Any chronic medical conditions?
● Previous hospitalizations?
● Previous surgeries?
Medications/Allergies
● What medications has she received?
● Has she received acetaminophen or ibuprofen?
● How much medication was given?
● When was the last dose?
● Any prescription medications?
● Any medication allergies?
● Any food or environmental allergies?
