Grady Harris "Tummy Ache"
Grady Harris, 26-month-old with Down syndrome, 2-day history of stomach pain.
, Reason for Enc
Stomach ache/abdominal pain with fall
HPI
T.A. is a 26 month old male with Down Syndrome presents today with a 2 day
history of abdominal pain, emesis x1, lethargy, diaphoresis without fever,
tachypnea and decreased urination. Mom notes these symptoms began after the
child fell out of a bed during his nap. She denies any head trauma but has noticed a
decrease in eating, drinking and interaction.
General
Complaints of listlessness, fatigue/lethargy, decreased energy. Denies fever, chills,
weight change, and night sweats
HEENT/Neck
Denies head trauma, bruising or bleeding.
Denies corrective lenses, redness, or vision changes. Denies ear pain, loss or
discharge
Denies congestion, nose bleeds, nasal discharge or sinus problems
Denies throat pain or foul smelling breath
CVD
known history of ASD with repair with murmur
Mom denies syncopal episodes, chest pain, edema, or peripheral cyanosis
Resp
Breathing is faster than normal per mother. Denies any cough, shortness of breath,
wheezing or hemoptysis. Patient does have history of pneumonia
GI complains of abdominal pain, vomiting x1 episode and
decreased oral intake Denies diarrhea, constipation, red/black
tarry stools.
GU
Mom described urine as darker than usual with foul odor and less frequent.
Decreased water intake. Denies hematuria, urgency, or frequency
Musculoskeletal
Denies noticeable pain in the back, swelling, stiffness or fracture history
Grady Harris, 26-month-old with Down syndrome, 2-day history of stomach pain.
, Reason for Enc
Stomach ache/abdominal pain with fall
HPI
T.A. is a 26 month old male with Down Syndrome presents today with a 2 day
history of abdominal pain, emesis x1, lethargy, diaphoresis without fever,
tachypnea and decreased urination. Mom notes these symptoms began after the
child fell out of a bed during his nap. She denies any head trauma but has noticed a
decrease in eating, drinking and interaction.
General
Complaints of listlessness, fatigue/lethargy, decreased energy. Denies fever, chills,
weight change, and night sweats
HEENT/Neck
Denies head trauma, bruising or bleeding.
Denies corrective lenses, redness, or vision changes. Denies ear pain, loss or
discharge
Denies congestion, nose bleeds, nasal discharge or sinus problems
Denies throat pain or foul smelling breath
CVD
known history of ASD with repair with murmur
Mom denies syncopal episodes, chest pain, edema, or peripheral cyanosis
Resp
Breathing is faster than normal per mother. Denies any cough, shortness of breath,
wheezing or hemoptysis. Patient does have history of pneumonia
GI complains of abdominal pain, vomiting x1 episode and
decreased oral intake Denies diarrhea, constipation, red/black
tarry stools.
GU
Mom described urine as darker than usual with foul odor and less frequent.
Decreased water intake. Denies hematuria, urgency, or frequency
Musculoskeletal
Denies noticeable pain in the back, swelling, stiffness or fracture history
