I Human Case Samantha Graves

I Human Case Samantha Graves
Patient Information: SG, 18 mo Female, African American
CC: Nausea, Vomiting, Diarrhea, lack of appetite.
HPI: Patient is a Caucasian 18 mo old African American female who present to the clinic with
her mother for N,V,D, and poor appetites x2 days. Diarrhea started 2 days ago followed by N, V,
and lack of appetite. Mother reports her other daughter has been sick with similar symptoms
which have resolved after couple days. No similar day care illnesses reported. Diarrhea appears
to be more watery, runny, random of moderate severity per patient’s mother. Nothing seems to
make it better or worse and no treatment was attempted. Vomiting appears to consistent of milk
and small amounts of “stuff she ate”. Vomiting and nausea also reported as moderate in severity.
Pt able to keep down a small amount of Pedialyte and milk. Poor appetite and irritability also
reported x 2days since other symptoms of N, V, D began. No fever and pain associated have been
reported. Mother not sure if the child has lost weight so far. Mother also reports 4 wet diapers a
day compared to 5-6 wet diaper a day since the symptoms began two days ago. No previous
similar symptoms noted.
Current Medications: None
Allergies: NKDA
PMH: No History of major childhood illnesses.
No hospitalizations, surgeries, ER visits, or specialist provider visits since last well visit.
Diphtheria, tetanus, & acellular pertussis (DTaP: <7 yrs) DUE (4th dose)
Developmental: patient cognitive and psychological stage appropriate to pt’s age. Pt uses 10-15
words.
FMH:
4-year-old sister with previous similar symptoms – resolved in 2 days according to mother
SH:
Lives in an apartment with her mother, father and 4-year-old sister.
Mother: 32 yo, works as a teacher
Father: 36 yo, works as an engineer
History Questions for HPI, PMH, ROS...
Ask Mother: How can I help her today?
Ask Mother: How does her vomit look like?
Ask Mother: Does she regurgitate her old food?
Ask Mother: When did her N/V started?
Ask Mother: Has she had N/V like this before?