NR 602 SOAP Week 3 Case Study Presentation Sick Child.

NR 602 SOAP Week 3 Case Study Presentation Sick Child.Patient Information: P.W. 2 month old, Caucasian male (S) Subjective: CC: Nasal congestion and cough x 2 days HPI: P.W. is a 2 m.o. male who presents with mother for a follow-up appointment. Mother states that the patient was last seen in the office 2 days ago for bronchiolitis. Within the last 24 hours’ mother notes patient’s feedings have improved, and he is having better UOP, with at least 6+ diapers per day. Mother reports that patient’s cough and respirations sound more productive, and patient had spiked a fever of 100.5 last night. Mother gave the patient Tylenol last night and it helped reduce the fever, and the patient has been afebrile today. Mother notes no s/s of respiratory distress, WOB, and has had a normal appetite, but hasn’t been himself lately with low energy. No other sick household members. He is the only child in the household, and is up to date on 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