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NR602 Week 3 Pediatric Cough iHuman Case Study - Grady Turner

HEAL100 Health Care — exam and revision material · Other

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Health Care case material, 9 pages. Originally published on StudyMerit.

Pages
9
Academic year
2025/2026
Language
English

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NR 602 Week 3 iHuman Case Study Grady Turner 18 months 2’10” (86cm) 28.0lbs (12.7kg) Mother: Suzzy Turner Chief Complaint : Cough Ask 2 open ended Questions: “How can I help you today?” “Any other symptoms or concerns?” History of Present Illness (HPI): Key Findings: Organize with most important to least important - Mom states child has been sick with “just a common cold” - Stuffy nose /runny nose for 5 days ; nasal congestion worse at nigh t; no treatment given - Persistent dry cough - Cough started 3 days ago; mom unsure of what makes it better or worse ; no treatment given - Fever. Max temp=100.5 yesterday morning ; used acetaminophen and ibuprofen - Sick exposure from 5 y.o. brother being sick a couple of weeks ago from daycare - Mom usure of wheezing, but child has moments where she can “hear something coming from his chest or mouth” - Mom unsure if short of breath but has noticed child seems uncomfortable - Denies diarrhea, rash, skin itching/burning, sore throat, problems swallowing, abdominal pain, nausea/vomiting, constipation, ear pain , pain in teeth, swollen lymph nodes , muscle pain or cramping, nosebleeds, bleeding or bruising problems, - Normal urine output - NKA - Denies red/irritated eyes, denies tearing or itching - Dad is a smoker; smokes at home - No pets - No recent hospitalizations, accidents or trauma - Afebrile

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Health History (ROS) SUBJECTIVE INFO REASON FOR ENCOUNTER Cough HISTORY OF PRESENT ILLNESS G.T. is an 18 month old male who presents with a dry cough that started 3 days ago accompanied with nasal congestion and runny nose that started 5 days ago. He is accompanied by his mother, Suzzy. Mother states she is unsure if child has been short of brea th or wheezing, but on occasion can "hear something coming from his chest or mouth." Mother states child had fever yesterday with a maximum temperature of 100.5 degrees Fahrenheit. Mother reports there was a sick sibling in the home, but proximity between the siblings was avoided. Immunizations are up to date including seasonal influenza and COVID booster. Child has not received RSV vaccine. GENERAL Accompanied by mother, Suzzy Turner. Alert, interactive, well - appearing child in no acute distress observed. Reported fever yesterday. Alternated between acetaminophen and ibuprofen for relief. HEENT/NECK Head: unsure of if experiencing headache s; denies trauma Eyes: Denies itching or tearing eyes , redness or irritation Ears: Denies ear pain. Nose: Reports runny nose and nasal congestion for 4 days that gets worse at night. No treatment given Throat: Denies sore throat, difficulty swallowing CARDIOVASCULAR Deferred RESPIRATORY Persistent dry cough started 3 days ago; unsure of what makes it better or worse. No treatment given. Mom usure of wheezing, but child has moments where she can “hear something coming from his chest or mouth”. Mom unsure if short of breath but has noticed child seems uncomfortable. GI Appetite i s decreased, but drinking is “normal”. Denies nausea, vomiting, abdominal pain , diarrhea, constipation, melena. GU Urine output is “normal”, denies hematuria MUSCULOSKELETAL/ OSTEOPATHIC Denies muscle pain or cramping NEUROLOGIC Deferred INTEGUMENTARY/BREAST Denies rash PSYCHIATRIC Deferred ENDOCRINE Urine output is reported as “normal” HEMATOLOGIC/ LYMPHATIC Denies swollen lymph nodes. ALLERGIC/IMMUNLOGIC No known allergies. PAST MEDICAL HISTORY No significant medical history. Denies any recent trauma or injuries.

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HOSPITALIZATIONS/SURGERIES None PREVENTATIVE HEALTH Immunizations up to date. Received seasonal influenza vaccine and COVID booster. Did not receive RSV vaccine MEDICATIONS OTC acetaminophen and ibuprofen every 4 to 6 hours as needed. ALLERGIES No known allergies. SOCIAL HISTORY Dad smokes at home and is reportedly trying to quit. FAMILY HISTORY Paternal grandfather is 67 years - old with hypertension. Paternal grandmother is 67 years - old and has diabetes. Maternal grandfather is 68 years - old and has hypertension. Maternal grandmother is 65 years - old and has diabetes. Mom is 33 years - old and dad is 35 years - old. Both are alive and well. Brother is 5 years - old and has seasonal allergies.

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