Lataille.Week6.SOAP

Document Content and Description Below

CC- Vomiting over the last 2 days and have developed diarrhea in the last 24 hours HPI- Both the oldest and youngest children in the house have had several episodes of vomiting over the last 2 days a... nd have developed diarrhea in the last 24 hours. Lilly has not vomited today. They have both had low-grade fevers of around 100 to 101 degrees in the afternoons. Mother reports that both have not eaten solid food since 36 hours prior to this visit, when they went to a pizza buffet in a town nearby. They have been keeping down some sprite, apple juice, and popsicles. Both urinated this morning. Mother has given both children Pepto-Bismol over the counter (OTC) to prevent an upset stomach and acetaminophen two to three times a day for fever. Lily is complaining of some lower abdominal pain starting this morning, but also reports she has started menses today. Lilly complains also of headache, myalgia. Her pain is a 5 on a 1- 10 scale and has progressed in the last hour. No other household members are ill. Current medications- None Immunizations: T-dap, HPV, Meningococcal (received last visit) Allergies- None PMH- Includes being a full-term vaginal delivery weighing 7lb 4 oz. She experienced a right radial fracture at age 8 and tonsillectomy and adenoidectomy at age 9. Social history- Sophomore in high school, denies sexual activity, drug or alcohol use. The children currently live with their mother and maternal grandparents for the last 8 weeks. Their father is involved but lives 2 hours away in the state capital where he works. Family history- They are maternal and paternal smokers. The mother has been one since age 22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no diseases reported in either parent. Mother has a history with gestational diabetes and preeclampsia. MGM has a history of hyperlipidemia, Type 2 DM, and Hypertension. They are Latin American in descent, emigrated from Cuba in the 1970s. MGF has a history of hypertension, hyperlipidemia, and an MI with stenting 2 years ago. The mother has two siblings; one who died in an MVA 5 years ago at the age of 18 a younger brother, and an older sister who is 42 and lives in a large urban city in the Midwest with her family, and she is in good health. Other family members died of old age. She is unaware of paternal familial health history. .......................................CONTINUED................................ [Show More]

Last updated: 1 year ago

Preview 1 out of 10 pages