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1. Doorway
Name: Jake
infor-
Mason. DOB:
mation
August 14th.
Age: 18-months-
old. Gender:
Male.
Primary language: English.
Admitting care provider: Emily Michaels, MD.
MRN: 7821478.
Your patient today is Jake Mason, an 18-month-old male. Jake presents
with a two-day history of congested coughing with a thick yellow
sputum expectorated. His cough is worse at night. His father has
brought him to the urgent care clinic for treatment.
2. Orders
(Health Care Admission Orders
Provider) Physician/Unit: Dr. Michels/Urgent Care.
Diagnosis: Cough
Condition:
Stable.
Vitals: Once.
Allergies: No known.
Medications: Dr. Micahels will be in shortly to see the patient.
3. Admitting
Notes (Health Admitting Notes (Health Care Provider)Reason for Encounter: Cough with a
Care Provider) thick sputum expectorated.
HPI: Jake Mason is an 18-month-old male with a two-day history of
congested coughing with a thick, yellow sputum expectorated. The
patient's cough is worse at night. His father has brought him to the
urgent care clinic for treatment.
Other Concerns: None.
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11
, JAKE MASON – IHUMAN EXAM QUESTION &
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surgeries. Medications:
Med surg: • Gestational
age at birth (37 weeks).
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