Uploaded by nergize13


Established Patient
Date: 9/12/19
Patient: 4 year old female
CC: “She woke up this morning with a fever and isn’t wanting to eat or drink”
HPI: Pt presents to the office with her mom. Mom states she came into her parents bed
at 3am this morning because she didn’t feel good. Mom states the patient felt very warm
but she didn’t have her thermometer. She gave the patient a dose of children’s Motrin
and states the patient was acting normal afterwards for about 4 hours. She didn’t feel
like eating breakfast or drinking anything. Pt told mom her throat hurt. Per mom, patient
hasn’t had any diarrhea or vomiting. She is able to eat popsicles. Mom felt like pt was
getting warm again but wanted to wait until appt to give Motrin again. Per mom, siblings
are healthy but pt was around another school aged child who stayed home sick today.
PMH: no health history
Immunizations: not vaccinated
PSH: no surgical history
Social History: Pt is a usual active and healthy four year old. She currently stays at
home with mom during the day. Has two older siblings age 11 and 8 who are attend
public school. Has one dog at home.
Family History:
Mother- seasonal allergies
Older brother- exercise induced asthma, seasonal allergies
No Known Drug Allergies
Current Medications
1) children’s gummy multivitamin 2 gummies, qday
questions answered by mom
Constitutional: fever and fatigue, no chills
Head: denies visual changes, redness, or drainage
Ears: denies tinnitus, hearing loss, drainage
Nose: clear nasal drainage, no r