TYPHON CASE log #: Date: Time: 10:15
05/20/2025
Patient initials (fictitious): A. B. Age: 9 Gender: Male
years.
(S) SUBJECTIVE: This is what the patient tells the provider.
Chief Concern (CC): “My right ear hurts and has fluid coming out”
HPI: A.B. is a 9-year-old mixed race- African American/Asian American- male with
no prior medical history, presents to the clinic accompanied by his father stating
complaints of right ear pain and yellow drainage and fever for the past two days.
A.B.’s father reports that his son's highest temperature was 101F on Friday but
resolved with Tylenol. He continues to report that since Saturday his son has been
complaining of constant right ear pain and pt’s mother also noticed yellow fluid
coming from that ear. He has been putting cotton balls in his son's right ear to
absorb the drainage at night, because the drainage on the pillow was waking the
patient up when he encountered it. A.B. was asked the faces scale to rate his ear
pain and pointed to the ‘hurts little more’ face. Pt and his father denied vomiting or
diarrhea; however, his father states he has not been eating or drinking much since
Saturday because “my throat was beginning to hurt too”. Denies his son being in
contact with anyone sick. Denies trauma to the right ear
Medications:
Tylenol Children’s- 7.5 mL oral every 4 hours as needed for pain/fever
PMH: List approximate year of diagnosis of disease or when surgical procedure
performed
Allergies: NKA/NKDA
Immunizations:
Age Date Vaccine(s)
Birth May 19, 2016 HepB #1
2 mo Jul 19, 2016 DTaP #1, IPV #1, Hib #1, PCV13 #1, RV #1, HepB #2
4 mo Sep 19, 2016 DTaP #2, IPV #2, Hib #2, PCV13 #2, RV #2
DTaP #3, IPV #3, Hib #3, PCV13 #3, RV #3, HepB #3, Flu
6 mo Nov 19, 2016
#1
12–15 Aug–Nov
MMR #1, Varicella #1, Hib final, PCV13 final, HepA #1
mo 2017
18 mo Nov 19, 2017 DTaP #4, HepA #2
, 4–6 yr 2020–2022 DTaP #5, IPV #4, MMR #2, Varicella #2, Annual Flu
Age 9 2024–2025 Flu (possibly COVID, HPV)
Medication Intolerances: none known.
Birth History: A.B’s father, and mother via phone call, deny any complications with
his pregnancy and birth.
Chronic Illnesses/Major traumas: A.B’s father, and mother via phone call deny
any chronic illness or trauma.
Hospitalizations/Surgeries. A.B’s father, and mother via phone call denies any past
hospitalization and denies any surgical history
Health Promotion/maintenance:
Dental: Last exam was over a year ago
Vision: Never had an eye examination w/ ophthalmology.
Family History:
Father- 33 y/o: alive and well. Mother- 34 y/o, alive and well managed Hashimoto’s.
Sister- 7 y/o, alive and well. Sister: 4 y/o alive and well.
Paternal Grandmother- 62 y/o. alive and well, recent left knee replacement for
arthritis.
Social History:
Education level: He is a 4th grader of Blue Lake Elementary in DeLand. Father
states he does well in school- no formal complaints of attention space or poor
performance. Pt states he really likes his math teacher because he makes it fun. Pt
also states he has “a tight group of friends, there are 4 of us, we are like
brothers”.
Current living situation: Patient reports he lives at home, “a regular house” with
both his parents and his grandmother lives 3 doors down and he will spend time
after school at her house.
05/20/2025
Patient initials (fictitious): A. B. Age: 9 Gender: Male
years.
(S) SUBJECTIVE: This is what the patient tells the provider.
Chief Concern (CC): “My right ear hurts and has fluid coming out”
HPI: A.B. is a 9-year-old mixed race- African American/Asian American- male with
no prior medical history, presents to the clinic accompanied by his father stating
complaints of right ear pain and yellow drainage and fever for the past two days.
A.B.’s father reports that his son's highest temperature was 101F on Friday but
resolved with Tylenol. He continues to report that since Saturday his son has been
complaining of constant right ear pain and pt’s mother also noticed yellow fluid
coming from that ear. He has been putting cotton balls in his son's right ear to
absorb the drainage at night, because the drainage on the pillow was waking the
patient up when he encountered it. A.B. was asked the faces scale to rate his ear
pain and pointed to the ‘hurts little more’ face. Pt and his father denied vomiting or
diarrhea; however, his father states he has not been eating or drinking much since
Saturday because “my throat was beginning to hurt too”. Denies his son being in
contact with anyone sick. Denies trauma to the right ear
Medications:
Tylenol Children’s- 7.5 mL oral every 4 hours as needed for pain/fever
PMH: List approximate year of diagnosis of disease or when surgical procedure
performed
Allergies: NKA/NKDA
Immunizations:
Age Date Vaccine(s)
Birth May 19, 2016 HepB #1
2 mo Jul 19, 2016 DTaP #1, IPV #1, Hib #1, PCV13 #1, RV #1, HepB #2
4 mo Sep 19, 2016 DTaP #2, IPV #2, Hib #2, PCV13 #2, RV #2
DTaP #3, IPV #3, Hib #3, PCV13 #3, RV #3, HepB #3, Flu
6 mo Nov 19, 2016
#1
12–15 Aug–Nov
MMR #1, Varicella #1, Hib final, PCV13 final, HepA #1
mo 2017
18 mo Nov 19, 2017 DTaP #4, HepA #2
, 4–6 yr 2020–2022 DTaP #5, IPV #4, MMR #2, Varicella #2, Annual Flu
Age 9 2024–2025 Flu (possibly COVID, HPV)
Medication Intolerances: none known.
Birth History: A.B’s father, and mother via phone call, deny any complications with
his pregnancy and birth.
Chronic Illnesses/Major traumas: A.B’s father, and mother via phone call deny
any chronic illness or trauma.
Hospitalizations/Surgeries. A.B’s father, and mother via phone call denies any past
hospitalization and denies any surgical history
Health Promotion/maintenance:
Dental: Last exam was over a year ago
Vision: Never had an eye examination w/ ophthalmology.
Family History:
Father- 33 y/o: alive and well. Mother- 34 y/o, alive and well managed Hashimoto’s.
Sister- 7 y/o, alive and well. Sister: 4 y/o alive and well.
Paternal Grandmother- 62 y/o. alive and well, recent left knee replacement for
arthritis.
Social History:
Education level: He is a 4th grader of Blue Lake Elementary in DeLand. Father
states he does well in school- no formal complaints of attention space or poor
performance. Pt states he really likes his math teacher because he makes it fun. Pt
also states he has “a tight group of friends, there are 4 of us, we are like
brothers”.
Current living situation: Patient reports he lives at home, “a regular house” with
both his parents and his grandmother lives 3 doors down and he will spend time
after school at her house.
