NRNP 6541 Week 7 Assignment: i-Human Samantha Graves

NRNP 6541 Week 7 Assignment

Patient Information: SG, 18-month-old, African-American, Female

Subjective:

 CC (chief complaint): Vomiting and diarrhea

 HPI: Samantha is an 18-month-old female who presents today with her mother with complaints of vomiting and diarrhea times 2 days. Sister recently had similar symptoms. Her mother reports that Samantha has vomited 4-5 times daily for the past two days and had 3-4 episodes of liquid diarrhea daily for the past two days. Vomit is liquid with some partially digested food. Diarrhea is liquid. Denies coffee-ground emesis or blood in stool or vomit. No fever, cough, or decreased activity.  The mother does report concerns over decreased appetite. Had been taking Pedialyte and tolerating small amounts of Pedialyte and milk. Physical exam without signs of dehydration, abdominal pain, or rebound tenderness.

Current meds: None

 Allergies: NKDA

 Pertinent PMHx: Samantha is in generally good health. No pertinent past medical history was noted. She is up to date on immunizations and has regular check-ups. She has met all developmental milestones for her age and is at the 75th percentile for height and weightContinue

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