NRNP 6541 Primary Care of Adolescents and Children I-human Week 4
Patient Information: R.F., 6/yo, Female, Caucasian
Subjective:
CC :”Red Right Eye”
HPI: R.F. is a 6-year-old Caucasian female who presented to the clinic after being sent home
from school with a complaint of a red right eye that began 3 days ago. She is a student in
primary school and her mother reports that she has had no trauma to the eye. She also has had
purulent drainage from the right eye that “matts up” for three days that does not go away until
she washes it off. Her mother states she has also had nasal congestion that is mild. It is reported
that she has been in close contact with two other students in her class who have had similar
symptoms. His mother also states that she has brought her into the clinic due to the school
PR
requiring evaluation of the eye before she is able to return to class. No other symptoms were
reported, and her mother states no treatment for the right eye redness and discharge has been
utilized.
Current Medications: No medications in current use.
O
Allergies: No allergies reported
Pertinent PMHx: Patient is in general good health. There is no current or previous medical or
FD
surgical history for the patient.
Medical, surgical, obstetric, hospitalizations:
None
O
Vaccinations:
Up to date:
C
Hep B - series completed at 18 months
RV1 - series completed at 4 months
DTaP - series completed at 5 years
Hib - series completed at 15 months
PCV13 - series completed at 15 months
IPV - series completed at 5 years
IIV – Annual vaccination completed at 5 years
MMR - series completed at 5 years
VAR - series completed at 5 years
Hep A - series completed at 18 months
, Developmental: Cognitive stage : Preoperational (age 2-7 years)
Psychosocial: Erikson’s Stage 4: Industry vs Inferiority (Ages 5-12 years)
Soc Hx: Parents: Mother and father are married.
Home: Lives in a single family home with parents and older sister.
Pets: Dog.
Tobacco: No smoking in the home.
Mother: Dental hygienist; works full time
Father: Accountant; works full time
Sister: 3rd grader in the same elementary school as Adam.
Fam Hx:
Mother: 38 yo, healthy
PR
Father: 40 yo, healthy
History questions asked:
1. (Parent) How can I help her today?
O
2. (Child) How can I help you today?
3. (Parent) Has she noticed blurred vision?
FD
4. (Parent) Has she had any trauma to her eyes?
5. (Parent) Does she have any other symptoms or concerns we should discuss?
6. (Parent) Does she have a runny nose/nasal congestion?
7. (Parent) Does she have a cough?
8. (Parent) What treatments has she had for her eye problem?
O
9. (Parent) Does she have any pain in her eyes?
10. (Parent) Are there any other people she has had contact with who have a similar
eye problem?
C
11. (Parent) Can you tell me about any current or past medical problems she has had?
12. (Parent) Is she taking any prescription medications?
13. (Parent) Is she taking any over-the-counter or herbal medications?
14. (Parent) Are her immunizations up to date?
15. (Parent) Does she have any allergies?
16. (Parent) Any previous medical, surgical, or dental procedures?
ROS:
General/Constitutional:
• Patient is alert and oriented x 4. Negative for fatigue. Negative for weight loss, chills.
Communicative, appears uncomfortable, and answers questions appropriately.
Patient Information: R.F., 6/yo, Female, Caucasian
Subjective:
CC :”Red Right Eye”
HPI: R.F. is a 6-year-old Caucasian female who presented to the clinic after being sent home
from school with a complaint of a red right eye that began 3 days ago. She is a student in
primary school and her mother reports that she has had no trauma to the eye. She also has had
purulent drainage from the right eye that “matts up” for three days that does not go away until
she washes it off. Her mother states she has also had nasal congestion that is mild. It is reported
that she has been in close contact with two other students in her class who have had similar
symptoms. His mother also states that she has brought her into the clinic due to the school
PR
requiring evaluation of the eye before she is able to return to class. No other symptoms were
reported, and her mother states no treatment for the right eye redness and discharge has been
utilized.
Current Medications: No medications in current use.
O
Allergies: No allergies reported
Pertinent PMHx: Patient is in general good health. There is no current or previous medical or
FD
surgical history for the patient.
Medical, surgical, obstetric, hospitalizations:
None
O
Vaccinations:
Up to date:
C
Hep B - series completed at 18 months
RV1 - series completed at 4 months
DTaP - series completed at 5 years
Hib - series completed at 15 months
PCV13 - series completed at 15 months
IPV - series completed at 5 years
IIV – Annual vaccination completed at 5 years
MMR - series completed at 5 years
VAR - series completed at 5 years
Hep A - series completed at 18 months
, Developmental: Cognitive stage : Preoperational (age 2-7 years)
Psychosocial: Erikson’s Stage 4: Industry vs Inferiority (Ages 5-12 years)
Soc Hx: Parents: Mother and father are married.
Home: Lives in a single family home with parents and older sister.
Pets: Dog.
Tobacco: No smoking in the home.
Mother: Dental hygienist; works full time
Father: Accountant; works full time
Sister: 3rd grader in the same elementary school as Adam.
Fam Hx:
Mother: 38 yo, healthy
PR
Father: 40 yo, healthy
History questions asked:
1. (Parent) How can I help her today?
O
2. (Child) How can I help you today?
3. (Parent) Has she noticed blurred vision?
FD
4. (Parent) Has she had any trauma to her eyes?
5. (Parent) Does she have any other symptoms or concerns we should discuss?
6. (Parent) Does she have a runny nose/nasal congestion?
7. (Parent) Does she have a cough?
8. (Parent) What treatments has she had for her eye problem?
O
9. (Parent) Does she have any pain in her eyes?
10. (Parent) Are there any other people she has had contact with who have a similar
eye problem?
C
11. (Parent) Can you tell me about any current or past medical problems she has had?
12. (Parent) Is she taking any prescription medications?
13. (Parent) Is she taking any over-the-counter or herbal medications?
14. (Parent) Are her immunizations up to date?
15. (Parent) Does she have any allergies?
16. (Parent) Any previous medical, surgical, or dental procedures?
ROS:
General/Constitutional:
• Patient is alert and oriented x 4. Negative for fatigue. Negative for weight loss, chills.
Communicative, appears uncomfortable, and answers questions appropriately.
