NURS 5335 ID Case Study Family II final-2

ID Case Study Family II Subjective 12 year old Angela presents to the office with a complaint of a rash for 24 h. She is accompanied by her mother. Angela has also had a mildly runny nose and cough for 3 days. She has had a fever (101 degrees). She has not had any vomiting or diarrhea. Diet: Balanced diet with enough dairy, protein, fruits and vegetables. No change in appetite since symptoms began. Elimination: no problems with voiding or dysuria or constipation. Sleep: sleeps about 9 hours per night PMH: Born via cesarean section at 38 weeks’ gestation for a breech presentation. Since being discharged home at 4 days old, she has had no hospitalizations. She was seen in the ED at 5 years of age for sutures after she fell and struck her head on the corner of a table. She has asthma and is on Beclomethasone inhaler 2 puffs twice daily and albuterol inhaler 2 puffs as needed. Ashtma is well controlled. Family History: Mother (38 years old) has a history of migraine headaches. Her father (39 years old) is healthy and has no history of chronic medical conditions. Her 8 year old brother has type 1 DM. Social history: Angela is in middle school and is doing well according to her mother. Angela lives at home with her parents and her 8 year old brother. Her father is an engineer and her mother is an accountant. The family has a dog. Medications: Angela is not currently taking any OTC, or herbal medications. Her only medications are Beclomethasone and albuterol inhalers. She has NKDA and no food allergies or environmental allergies. After reviewing sho