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Exam (elaborations)

I Human Case Samantha Graves Patient Information: SG, 18 mo Female, African American

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Patient Information: SG, 18 mo Female, African American CC: Nausea, Vomiting, Diarrhea, lack of appetite. HPI: Patient is a Caucasian 18 mo old African American female who present to the clinic with her mother for N,V,D, and poor appetites x2 days. Diarrhea started 2 days ago followed by N, V, and lack of appetite. Mother reports her other daughter has been sick with similar symptoms which have resolved after couple days. No similar day care illnesses reported. Diarrhea appears to be more watery, runny, random of moderate severity per patient’s mother. Nothing seems to make it better or worse and no treatment was attempted. Vomiting appears to consistent of milk and small amounts of “stuff she ate”. Vomiting and nausea also reported as moderate in severity. Pt able to keep down a small amount of Pedialyte and milk. Poor appetite and irritability also reported x 2days since other symptoms of N, V, D began. No fever and pain associated have been reported. Mother not sure if the child has lost weight so far. Mother also reports 4 wet diapers a day compared to 5-6 wet diaper a day since the symptoms began two days ago. No previous similar symptoms noted. Current Medications: None Allergies: NKDA PMH: No History of major childhood illnesses. No hospitalizations, surgeries, ER visits, or specialist provider visits since last well visit. Diphtheria, tetanus, & acellular pertussis (DTaP: 7 yrs) DUE (4th dose) Developmental: patient cognitive and psychological stage appropriate to pt’s age. Pt uses 10-15 words. FMH: 4-year-old sister with previous similar symptoms – resolved in 2 days according to mother SH: Lives in an apartment with her mother, father and 4-year-old sister. Mother: 32 yo, works as a teacher Father: 36 yo, works as an engineer History Questions for HPI, PMH, ROS... Ask Mother: How can I help her today? Ask Mother: How does her vomit look like? Ask Mother: Does she regurgitate her old food? Ask Mother: When did her N/V started? Ask Mother: Has she had N/V like this before? This study source was downloaded by from CourseH on 06-08-2023 04:07:07 GMT -05:00 Ask Mother: Does anything make her N/V better or worse? Ask Mother: Is she taking any meds for her symptoms? Ask Mother: When and what did she eat last? Ask Mother: Does she have any pain and if so, where? Ask Mother: Has she lost weight? Ask Mother: Has she had any fevers? Ask Mother: Does she have any pain in her abdomen? Ask Mother: Has she had any contact with other sick people? Ask Mother: What are the events surrounding the start of her diarrhea? Ask Mother: Does she have black-tar- like foul smelling stools? Ask Mother: Does anything make the diarrhea better or worse? Ask Mother: What tx has she had for her diarrhea? Ask Mother: How severe is her N/V? Ask Mother: How severe is her diarrhea? Ask Mother: Can you tell me about her diet? What does she eat? Ask Mother: Does she eat raw or undercooked meat? Ask Mother: Does she have any other symptoms or concerns we should discuss? Ask Mother: Any changes in the frequency of her bowel movement? Ask Mother: Any problems with fatigue/tiredness? Ask Mother: How quickly does her diarrhea come on? Ask Mother: Has she eating anything out of the ordinary lately? Ask Mother: Any recent travel? Ask Mother: Are her immunizations up to date? Ask Mother: Does she go to daycare? Ask Mother: Any diseases that run in the family? Ask Mother: Anything new in the family hx I should know about? Ask Mother: How many wet diapers in a day? Ask Mother: Is your child meeting the development milestones? Ask Mother: How is her overall health? Ask Mother: What is the color of the urine and has it changed lately? Ask Mother: Any runny nose, congestion…. Ask Mother: Any chest pain, discomfort, pressure ….? Ask Mother: SOB, wheezing….? Ask Mother: Any muscle pain, joint swelling….? Ask Mother: Dizziness, fainting, weakness…? ROS: SUBJECTIVE This study source was downloaded by from CourseH on 06-08-2023 04:07:07 GMT -05:00  General/ Constitutional: No fever  Skin/Breast: Skin is warm, Dry, no lesions seen. Normal turgor  HEENT and Neck:  Cardiovascular: No new findings reported. No history of murmur, no shortness of breath. No history of fainting or excessive sweating.  Respiratory: No Nasal congestion, no cough, no wheezing, no SOB reported  Abdomen/GI: N, V, random Diarrhea, lack of appetite x 2days. Diarrhea is runny and watery  Genitourinary: 4 wet diaper a day. urine appear pale yellow.  Musculoskeletal: No changes from previous visit. No new finding reported.  Neurological: No changes from previous visit. No new finding reported.  Allergic/Immunologic: No allergies. Diphtheria, tetanus, & acellular pertussis (DTaP: 7 yrs) DUE (4th dose)  Lymphatic/Endocrine: No changes from previous visit. No new finding reported.  Hematologic: No changes from previous visit. No new finding reported.  Psychological: Happy child per mother. Fussy and irritable since onset of symptoms x 2 days OBJECTIVE VS: BP 88/50, RR 24, P 130, T 98.6C,SPO2 94% RA, H 2’8”, W 26lbs, BMI 17.9, AAOx4, 56 Percentile General: Well-developed 18-month-old African American who is alert and cooperative. Accompanied by parent. Skin/Breast: Skin is warm and dry. No lesions noted. Normal turgor HEENT: Normocephalic, atraumatic. CV: S1 and S2 present. RRR. No M, G, R. RESP: Normal respiratory effort and excursion Breath sounds equal with no wheezing or crackles.

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Institution
Walden University
Course
NRNP6541 / NURS 6541

Content preview

I Human Case Samantha
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GravesPatient Information: SG, 18 mo Female,
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i African American i




CC: Nausea, Vomiting, Diarrhea, lack of appetite.
i i i i i i




HPI: Patient is a Caucasian 18 mo old African American female who present to
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the clinic with her mother for N,V,D, and poor appetites x2 days. Diarrhea
i i i i i i i i i i i i i




started i




2 days ago followed by N, V, and lack of appetite. Mother reports her other
i i i i i i i i i i i i i i




daughter has been sick with similar symptoms which have resolved after couple
i i i i i i i i i i i i




days. No similar day care illnesses reported. Diarrhea appears to be more watery,
i i i i i i i i i i i i i




runny, random of moderate severity per patient’s mother. Nothing seems to make
i i i i i i i i i i i i




it better or worse and no treatment was attempted. Vomiting appears to consistent
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of milk and small amounts of “stuff she ate”. Vomiting and nausea also reported
i i i i i i i i i i i i i i




as moderate in severity. Pt able to keep down a small amount of Pedialyte and
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milk. Poor appetite and irritability also reported x 2days since other symptoms of
i i i i i i i i i i i i i




N, V, D began. No fever and pain associated have been reported. Mother not sure
i i i i i i i i i i i i i i i




if the child has lost weight so far. Mother also reports 4 wet diapers a day
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compared to 5-6 wet diaper a day since the symptoms began two days ago. No
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previous i




similar symptoms noted. i i




Current Medications: None
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Allergies: NKDA
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PMH: No History of major childhood illnesses. i i i i i i




No hospitalizations, surgeries, ER visits, or specialist provider visits since last well
i i i i i i i i i i i




i visit. Diphtheria, tetanus, & acellular pertussis (DTaP: <7 yrs) DUE (4th dose)
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Developmental: patient cognitive and psychological stage appropriate to pt’s age. i i i i i i i i i




Pt uses 10-15 words.
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FMH:
4-year-old sister with previous similar symptoms – resolved in 2 days according to i i i i i i i i i i i i




This study source was
i i i i i i i i downloaded by 100000847555400 i i i i i i from CourseHero.com i i i i on i i 04-13-2023


https://www.coursehero.com/file/180750677/I-Human-Case-Samantha-Gravesdocx/

, mother i




SH:




This study source was
i i i i i i i i downloaded by 100000847555400
i i i i i i from CourseHero.com
i i i i on i i 04-13-2023


https://www.coursehero.com/file/180750677/I-Human-Case-Samantha-Gravesdocx/
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Institution
Walden University
Course
NRNP6541 / NURS 6541

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Uploaded on
August 27, 2025
Number of pages
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Written in
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