NR602 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 night; 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
, 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 breath 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 headaches; 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 is decreased, but drinking is “normal”. Denies nausea,
vomiting, abdominal pain, diarrhea, constipation, melena.
GU Urine output is “normal”, denies hematuria
MUSCULOSKELETAL/ Denies muscle pain or cramping
OSTEOPATHIC
NEUROLOGIC Deferred
INTEGUMENTARY/BREAST Denies rash
PSYCHIATRIC Deferred
ENDOCRINE Urine output is reported as “normal”
HEMATOLOGIC/ Denies swollen lymph nodes.
LYMPHATIC
ALLERGIC/IMMUNLOGIC No known allergies.
PAST MEDICAL HISTORY No significant medical history. Denies any recent trauma or
injuries.
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 night; 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
, 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 breath 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 headaches; 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 is decreased, but drinking is “normal”. Denies nausea,
vomiting, abdominal pain, diarrhea, constipation, melena.
GU Urine output is “normal”, denies hematuria
MUSCULOSKELETAL/ Denies muscle pain or cramping
OSTEOPATHIC
NEUROLOGIC Deferred
INTEGUMENTARY/BREAST Denies rash
PSYCHIATRIC Deferred
ENDOCRINE Urine output is reported as “normal”
HEMATOLOGIC/ Denies swollen lymph nodes.
LYMPHATIC
ALLERGIC/IMMUNLOGIC No known allergies.
PAST MEDICAL HISTORY No significant medical history. Denies any recent trauma or
injuries.
