Chamberlain College of Nursing - NR 602week3.soap.NR602.

Soap Week 3 R.F 17months old, F S: CC: Fever, rash, rhinorrhea and cough. HPI: Riley is a 17month old male, brought in to the clinic by his mom due to fever as high as 103,104F and rash to the torso and abdomen. Mother reports that Riley also has rhinorrhea and cough. Mother reports that Riley is drinking, but not as well as usual. “He did have a good wet diaper this morning, but is not really eating much and is not playing” Fever: Onset: a couple of days ago. Location: generalized. Duration: ongoing. Characteristics: normal levels in the morning then gets as high as 103 to 104 degrees in the afternoons. Aggravating Factors: not really eating much and is not playing Relieving factors: none, not improving, after 3days. Treatment: Liquid Tylenol ½ a tsp Rash: Onset: 24hrs ago. Location: torso and abdomen, Duration: ongoing. Characteristics: Red, diffuse rash to the torso and abdomen that does not itch. Aggravating Factors: Riley is not really eating much and is not playing Relieving factors: unknown. Treatment: none Rhinorrhea: Onset: a couple of days ago. Location: nose Duration: ongoing. Characteristics: clear rhinorrhea cough. Aggravating Factors: Riley is not really eating much and is not playing, has wet diaper. Relieving factors: Robitussin. Treatment: none PMH: Born at 34weeks