Student Name: Brougan Sheets
Patient Initials: M.B.
Course: NUR 625L (Pediatrics I)
Date: 11/25/24
S CC M.B. is a healthy appearing unvaccinated 15 month old that presents to
the clinic today with her mother and father who provide the history,
and her 6 other elder siblings with complaint of cough for the last 2
weeks.
She is a new patient to our practice recently moved to the area from
Colorado.
HPI Today they report that she started 2 weeks ago with a dry cough that
has worsened in the last 24 hours. She has long episodes of
unrelenting cough and she is now wheezing. They report that she is not
vaccinated. The entire family has been sick with the same symptoms in
the last month at one time or another. The parents are unable to give
exact time line on illnesses amongst everyone.
Everyone else has gotten better except for Maria and her dad. She was
eating and drinking normally until 1 day ago when she started only
eating and drinking about 25% of her usual in take. They also report
she is having 4-6 wet diapers per day and has had 2 stools today but
they are a little looser than normal.
They report that they have had several of their friends whose children
have had pertussis in recent weeks that their children have been
around. Maria has not had increased work of breathing or distress.
The patient has no significant medical history aside from being un-
immunized. Parents have not administered any medications other than
arnica. Father and sister have a history of asthma and mother reports
that when M.B. gets colds it always seems to go to her chest so she
would not be surprised if Maria has asthma as well but she has never
required breathing treatments.
,Student Name: Brougan Sheets
Patient Initials: M.B.
Course: NUR 625L (Pediatrics I)
Date: 11/25/24
However, today is her first visit to the doctor since her birth. She has
not had fever.
Current/PMH No previous medical history
Surgical Hx No surgical medical history
Medications She does not and has not ever taken medication according to the
parents
Allergies She has no known medication, seasonal, or food allergies
Family Hx Father: Asthma
Sister: Asthma
There is no maternal, paternal, grand-maternal or grand-paternal
previous medical history that M.B’s parents are aware of.
Social Hx Lives at home with mom, dad, 6 brothers and 1 sister. They have
rabbits, goats, chickens and a cat. Everyone inn the home are non-
smokers. All children are homeschooled. They do participate in
weekly homeschool co-operatives.
Mother stays at home.
Father is a plumber and owns his own plumbing business.
ROS Review of Systems
Constitutional: Positive for appetite change. Negative for activity
change and fever.
HENT: Positive for congestion and rhinorrhea.
Respiratory: Positive for paroxysmal cough and wheezing.
Gastrointestinal: Negative for diarrhea and vomiting.
Genitourinary: Negative for decreased urine volume.
, Student Name: Brougan Sheets
Patient Initials: M.B.
Course: NUR 625L (Pediatrics I)
Date: 11/25/24
Skin: Negative for rash.
Psychiatric/Behavioral: Positive for sleep disturbance.
Immunization The patient has no history of immunizations. None of the children are
s immunized. The family is adamant that if we continue to push them to
immunize they will no longer seek medical care for their children.
O Exam Physical Exam
Vitals and nursing note reviewed.
Pulse 133
Temp 97.7 °F (36.5 °C) (Axillary)
Resp 36
Weight: 17lbs 15 oz
SpO2 99%
Constitutional:
General: She is active. She is not in acute distress.
Appearance: Normal appearance. She is well-developed. She is not
diaphoretic.
Comments: Cooperative, happy and active in no distress
HENT:
Head: Normocephalic and atraumatic.
Right Ear: Tympanic membrane normal.
Left Ear: Tympanic membrane normal.
Nose: Congestion present.
Mouth/Throat:
Mouth: Mucous membranes are moist.
Pharynx: Oropharynx is clear.
Tonsils: No tonsillar exudate.
Eyes:
General:
Patient Initials: M.B.
Course: NUR 625L (Pediatrics I)
Date: 11/25/24
S CC M.B. is a healthy appearing unvaccinated 15 month old that presents to
the clinic today with her mother and father who provide the history,
and her 6 other elder siblings with complaint of cough for the last 2
weeks.
She is a new patient to our practice recently moved to the area from
Colorado.
HPI Today they report that she started 2 weeks ago with a dry cough that
has worsened in the last 24 hours. She has long episodes of
unrelenting cough and she is now wheezing. They report that she is not
vaccinated. The entire family has been sick with the same symptoms in
the last month at one time or another. The parents are unable to give
exact time line on illnesses amongst everyone.
Everyone else has gotten better except for Maria and her dad. She was
eating and drinking normally until 1 day ago when she started only
eating and drinking about 25% of her usual in take. They also report
she is having 4-6 wet diapers per day and has had 2 stools today but
they are a little looser than normal.
They report that they have had several of their friends whose children
have had pertussis in recent weeks that their children have been
around. Maria has not had increased work of breathing or distress.
The patient has no significant medical history aside from being un-
immunized. Parents have not administered any medications other than
arnica. Father and sister have a history of asthma and mother reports
that when M.B. gets colds it always seems to go to her chest so she
would not be surprised if Maria has asthma as well but she has never
required breathing treatments.
,Student Name: Brougan Sheets
Patient Initials: M.B.
Course: NUR 625L (Pediatrics I)
Date: 11/25/24
However, today is her first visit to the doctor since her birth. She has
not had fever.
Current/PMH No previous medical history
Surgical Hx No surgical medical history
Medications She does not and has not ever taken medication according to the
parents
Allergies She has no known medication, seasonal, or food allergies
Family Hx Father: Asthma
Sister: Asthma
There is no maternal, paternal, grand-maternal or grand-paternal
previous medical history that M.B’s parents are aware of.
Social Hx Lives at home with mom, dad, 6 brothers and 1 sister. They have
rabbits, goats, chickens and a cat. Everyone inn the home are non-
smokers. All children are homeschooled. They do participate in
weekly homeschool co-operatives.
Mother stays at home.
Father is a plumber and owns his own plumbing business.
ROS Review of Systems
Constitutional: Positive for appetite change. Negative for activity
change and fever.
HENT: Positive for congestion and rhinorrhea.
Respiratory: Positive for paroxysmal cough and wheezing.
Gastrointestinal: Negative for diarrhea and vomiting.
Genitourinary: Negative for decreased urine volume.
, Student Name: Brougan Sheets
Patient Initials: M.B.
Course: NUR 625L (Pediatrics I)
Date: 11/25/24
Skin: Negative for rash.
Psychiatric/Behavioral: Positive for sleep disturbance.
Immunization The patient has no history of immunizations. None of the children are
s immunized. The family is adamant that if we continue to push them to
immunize they will no longer seek medical care for their children.
O Exam Physical Exam
Vitals and nursing note reviewed.
Pulse 133
Temp 97.7 °F (36.5 °C) (Axillary)
Resp 36
Weight: 17lbs 15 oz
SpO2 99%
Constitutional:
General: She is active. She is not in acute distress.
Appearance: Normal appearance. She is well-developed. She is not
diaphoretic.
Comments: Cooperative, happy and active in no distress
HENT:
Head: Normocephalic and atraumatic.
Right Ear: Tympanic membrane normal.
Left Ear: Tympanic membrane normal.
Nose: Congestion present.
Mouth/Throat:
Mouth: Mucous membranes are moist.
Pharynx: Oropharynx is clear.
Tonsils: No tonsillar exudate.
Eyes:
General:
