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Week 3: Case Presentation Study
Chamberlain University
NR602: Primary Care of the Childbearing and Childrearing Family
January 2018
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https://www.coursehero.com/file/29047733/NR602-Week-3-Case-Studydocx/
, WEEK 3: STUDY 2
SOAP Week 3
Patient Information:
H.H, 2 m.o. Caucasian female, UPMC insurance.
(S) Subjective:
CC: Nasal congestion and cough x 2 days
HPI:
H.H. is a 2 m.o. female who presents with mother for a follow-up appointment. Mother notes that
patient was seen 2 days ago for bronchiolitis. Over the course of the last 24hrs patient's feeding has
improved and she has had a greater UOP, 6+ wet diapers daily. Mother notes that patient's cough and
respirations sound more productive and last night patient developed a fever of 100.5. Mother phoned
Dr. S. last evening who advised that she administer to H.H. Tylenol and bring her in today for follow-up.
Mother notes that patient has been afebrile today with no cyanosis, s/s of respiratory distress or WOB.
Mother notes that she has been running a cool mist vaporizer in patient's room at night time and using
saline nasal spray 3-4x's daily. Patient has had normal appetite and energy, no recent travel or sick
household contacts, patient is up to date on her immunizations.
Current Medications:
Acetaminophen (TYLENOL) 160 mg/5 mL Susp suspension
Allergies: No known allergies.
PMHx: Birth History
• Birth
Length: 50.5 cm (19.88")
Weight: 7 lb 2.1 oz (3.235 kg)
• Apgar
One: 8
Five: 9
• Discharge Weight: 6 lb 13.7 oz (3.11 kg)
• Delivery Method: Vaginal, Spontaneous Delivery
• Gestation Age: 39 3/7 wks
Prenatal:
Maternal Blood Type A positive Antibody negative
Maternal hepatitis B surface antigen status: negative
Maternal HIV status: negative
Maternal RPR negative
Maternal Rubella negative
Maternal Group B strep: negative
Hepatitis C Antibody negative
CCHD Screen:
PSHx: None.
Immunization Hx:
DTaP/HepB/IPV 1/5/18
This study source was downloaded by 100000825073966 from CourseHero.com on 05-20-2021 20:36:01 GMT -05:00
https://www.coursehero.com/file/29047733/NR602-Week-3-Case-Studydocx/
Week 3: Case Presentation Study
Chamberlain University
NR602: Primary Care of the Childbearing and Childrearing Family
January 2018
This study source was downloaded by 100000825073966 from CourseHero.com on 05-20-2021 20:36:01 GMT -05:00
https://www.coursehero.com/file/29047733/NR602-Week-3-Case-Studydocx/
, WEEK 3: STUDY 2
SOAP Week 3
Patient Information:
H.H, 2 m.o. Caucasian female, UPMC insurance.
(S) Subjective:
CC: Nasal congestion and cough x 2 days
HPI:
H.H. is a 2 m.o. female who presents with mother for a follow-up appointment. Mother notes that
patient was seen 2 days ago for bronchiolitis. Over the course of the last 24hrs patient's feeding has
improved and she has had a greater UOP, 6+ wet diapers daily. Mother notes that patient's cough and
respirations sound more productive and last night patient developed a fever of 100.5. Mother phoned
Dr. S. last evening who advised that she administer to H.H. Tylenol and bring her in today for follow-up.
Mother notes that patient has been afebrile today with no cyanosis, s/s of respiratory distress or WOB.
Mother notes that she has been running a cool mist vaporizer in patient's room at night time and using
saline nasal spray 3-4x's daily. Patient has had normal appetite and energy, no recent travel or sick
household contacts, patient is up to date on her immunizations.
Current Medications:
Acetaminophen (TYLENOL) 160 mg/5 mL Susp suspension
Allergies: No known allergies.
PMHx: Birth History
• Birth
Length: 50.5 cm (19.88")
Weight: 7 lb 2.1 oz (3.235 kg)
• Apgar
One: 8
Five: 9
• Discharge Weight: 6 lb 13.7 oz (3.11 kg)
• Delivery Method: Vaginal, Spontaneous Delivery
• Gestation Age: 39 3/7 wks
Prenatal:
Maternal Blood Type A positive Antibody negative
Maternal hepatitis B surface antigen status: negative
Maternal HIV status: negative
Maternal RPR negative
Maternal Rubella negative
Maternal Group B strep: negative
Hepatitis C Antibody negative
CCHD Screen:
PSHx: None.
Immunization Hx:
DTaP/HepB/IPV 1/5/18
This study source was downloaded by 100000825073966 from CourseHero.com on 05-20-2021 20:36:01 GMT -05:00
https://www.coursehero.com/file/29047733/NR602-Week-3-Case-Studydocx/
