NR 603 Week 5 i-Human: 3-Year-Old Child with Barky Cough (Croup Case) – Complete Assessment & Plan 2026 premium case

NR 603 Week 5 i-Human: 3-Year-Old Child with Barky Cough (Croup Case) – Complete Assessment & Plan 2026 premium case Patient Information Initials C.P., Age 3 years old, Race: Caucasian, Gender: Female CC: For the past four days, the child has had a barky cough. The cough started on Sunday, but it became worse on Day 1 and 2 of symptoms. Between doses of Tylenol and Motrin, the child's temperature rose to 104 degrees on Day 2 evening and has since dropped to 101-102 degrees. The mother of the child observed that her top lip was somewhat swollen today, and the youngster refused to let her mother clean her nose. HPI: As previously noted, the patient had a four-day history of cough, with development of fever on the second day of symptoms. The cough is barky and worsens while the patient is lying down. She has lost her appetite and drinks less fluids by mouth. She has experienced clear nasal discharge and severe nasal congestion for many days. PMH: Birth History: The patient was a 36-week infant born to G1 P0→1 female. She weighed 5 lbs. 15 oz. at birth and had no complications. She was breast fed as an infant. Surgical History: none Hospitalizations: Birth Immunizations: immunizations were up-to-date and she had received routine well-child exams at 2-, 4-, 6-, 9-, 12-, 15-, 18-, 24-, and 36-month time points. She has had no developmental delays. Family History: No family history of Deafness, nasal allergies, asthma, TB, heart disease, hypertension, hypercholesterolemia, blood dyscrasias, liver disease, renal disease, diabetes, alcoholism, drug addiction, mental illness, mental retardation, and immunological illnesses or disorders. Demographics: The patient lives at home with her mother and father. Her mother is a registered nurse and works in Medical Surgical Nursing and her father works as a Private Investigator. The patient lives in a single-family home and has adequate resources for food, clothing, etc. Medications: 1. Tylenol 100mg/5ml 1 teaspoon q 4 hours prn fever, pain 2. Motrin 100mg/5ml 1 teaspoon q 6 hours prn fever pain Allergies: NKDA lOMoARcPSD| Social History/Lifestyle: Goes to Preschool 5 days a week from 9 am to 1 pm Monday through Friday. Review of Systems (Subjective): General Health: Healthy, vibrant child with no chronic disease. Currently with fever, cough, congestion, and lip edema. Skin/Hair/Nails: No excess sweating, rashes, dryness, hair loss or nail changes. HEENT: Denies headaches. No visual disturbances. Head/nasal congestion for approximately 4-5 days. No nasal congestion at present. Neck/Lymph: No lumps or swelling in neck. No tender lymph nodes. Breast: Deferred Chest/Lungs: No dyspnea with exercise. CV: No murmur. No edema of lower extremities. Peripheral Vascular: No changes in coloration of extremities. GI: Appetite fair. Denies signs and symptoms of gastro esophageal reflux. No food Allergies. No constipation or diarrhea. GU: Potty trained. Occasional nighttime accidents. Endocrine: No temperature intolerance. Polyuria, polydipsia, or polyphagia. M/S: No muscle weakness or pain. No difficulty with ambulation. Neurological: No dizziness, fainting, or seizure activity. Psychiatric: No anxiety. No behavioral concerns (Hollier, 2021). Physical Exam (Objective): Vital Signs: Height: 34 inches Weight: 30 lbs. Temp: 100.9 Pulse: 131 Respiratory Rate: 32 Pulse Ox: 100% BP: 84/67