I-HUMAN CASE WEEK 9 OF 30 YEAR OLD FEMALE|| REASON FOR ENCOUNTER :NECK PAIN||LOCATION OUTPATIENT CLINIC WITH X-RAY ,ECG AND LABORATORY CAPABILITIES

I- Human Case Week# 4 5YEAR OLD BOY, HEIGHT
:3’8”(112cm),WEIGHT 40.0LB(18.2kg)REASON FOR
ENCOUNTER:COUGH AND TROUBLE BREATHING
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, Chief Complaint:

 Cough and trouble breathing.

History of Present Illness:

 Onset: When did the cough and breathing trouble start?
 Duration: How long has it been going on?
 Progression: Getting better, worse, or staying the same?
 Character of cough: Dry or wet (productive)? Barky, whooping, or wheezy?
 Breathing trouble: Wheezing, grunting, nasal flaring, chest retractions?
 Triggers: Worse at night, with exercise, around allergens?
 Associated symptoms: Fever, runny nose, sore throat, vomiting, cyanosis (bluish
lips/skin), lethargy?
 Previous episodes: Any similar past episodes? (history of asthma, bronchiolitis,
pneumonia)
 Medications used: Any inhalers, antibiotics, or over-the-counter meds? Any effect?
 Allergies: Known allergies to food, pollen, pets, etc.?
 Vaccination status: Up to date? (especially pertussis, influenza, COVID, pneumococcal
vaccines)
 Exposure history: Sick contacts, daycare/school exposure, travel, smoke exposure, pets
at home?
 Past medical history: Asthma, prematurity, congenital heart disease, recurrent
infections?
 Family history: Asthma, allergies, atopy?

General Appearance:

 Alert, irritable, lethargic?
 Signs of respiratory distress (tripod position, anxious look)?

Vital Signs:

 Temperature (fever?)
 Heart rate (tachycardia?)
 Respiratory rate (tachypnea?)
 Oxygen saturation (hypoxia?)
 Blood pressure

HEENT (Head, Eyes, Ears, Nose, Throat):