Chamberlain College of Nursing NR 511 MMiller. Week3 SOAP Riley 18 months, male

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Riley 18 months, male Subjective Chief complaint: fever and rash History of present illness (HPI): O: Onset-three days ago and is of normal levels in the morning then gets as high as 100 to 101 d... egrees in the afternoons. L: Location— developed a red, diffuse rash to the torso and abdomen D: Duration-three days C: Characteristics/Associated symptoms- clear rhinorrhea in the last 24 hours. Rash that does not itch and a barking cough in the last day. Not eating, not playing, minimal drinking. A: Aggravating factors-not discussed R: relieving factors- temporary relief of coughing after robitussin for the cough, and tylenlol for fever T: Treatments- Mother has stopped the Zyrtec. She is giving Robitussin cough and cold at 2.5 ml last night and this morning. Liquid Tylenol 7.5 ml last night and this morning. S: Severity- Mother is very concerned about the level of the fever and the fact that after 3 days he is not improving. Past Medical History- Born at 34 weeks gestation via cesarean section, weight. 5 pounds 1 ounce. The mother developed preeclampsia and gestational diabetes. The mother quit smoking when she found out she was pregnant. Riley has allergies per mother and sometimes takes Cetrizine syrup 2.5ml once daily, PRN congestion, and a children’s chewable multivitamin daily. immunization history- Birth – Hep B, 2 months – DTaP, COMVAX, PCV13, IPV, 4 months - DTaP, COMVAX, PCV13, IPV, 6 months – DtaP, PCV 13, IPV, Hep B [Show More]

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