BRG-SON NURS 217 Community Assignment Pediatric Health History Student Name: Kaitlyn Capro I. Identifying Information Client initials: B.G. Address: n/a Telephone: n/a Birth date & location of birth: Race: Caucasian Sex: Male Religion: Nondenominational Date of interview: 03/20/2022 Informant: Mother January 21, 2014 II. Chief Complaint (major reason for seeking care; for purposes of assignment may be fictional or refer to previous MD visit): Shortness of breath, Increased Fatigue III. Present illness: Mother states that the patient is having difficulty breathing and keeps coughing, with increased fatigue since this morning. Patient has had a cold for the last 2-3 days and today was his first day back to school. Past history Birth history: Patient was born at 36 weeks’ gestation via vaginal delivery to 26yo mother G1P1. Mother’s prenatal screen revealed a negative Hepatitis B antigen, negative HIV screen, Rubella immune, and GBS negative; however, mom was diagnosed with Gestational Diabetes following both the one hour and the three-hour glucose tests. B.G.’s birth weight was 6.8 pounds and 21 inches long. There were no complications at delivery. APGAR’s are unknown but mom reported that the patient did breathe spontaneously at birth. Both mom and baby were discharged after a three-day hospital stay. B.G. did not require any respiratory support or phototherapy while in the nursery. Newborn screen was performed prior to discharge, but the results are unknown. IV. Previous illness, injuries, surgeries: Allergies: Recent upper respiratory infection. Mom denies any accidents and injuries. No known allergies Current medications: Cough medicine for the past 2 days. BRG-SON NURS 217 Community Assignment Pediatric Health History Student Name: Kaitlyn Capro Immunizations (if not available; for purposes of assignment may write all appropriate immunizations for client/patient age): Hepatitis B, Rotavirus, DTaP, Hib, PCV13, Inactivated Poliovirus, Influenza, MMR, Varicella, Hepatitis A, Growth and development: (developmental milestones, etc) - - - Habits (example: response to frustration, exercise, sleep, thumb sucking, etc.) V. Lifted head & chest while lying on stomach at 7 months old Sat alone without assistance around 8 months old Stood without support around 14 months Currently More independence, understanding of his place in the world, more attention to friendships and teamwork, rapid development of mental skills, better descriptions of experiences and talks about thoughts and feelings, less focus on oneself and more concern for others; prints first and last name, birthdate. Draws recognizable pictures Currently in the third grade with multiple friends that he talks about frequently; loves having the whole family together; to which his only birthday wish was “to be with family” Gets along with children his age and can determine when someone is not being nice/appropriate Better control of own behavior and emotions, easily embarrassed; some anxiety regarding health at times, learning to voice opinion, sleeps 8-10 hours per night; independent toileting and dressing Review of Systems Constitutional: Well-developed, well-nourished; fatigue/low energy reported. No fluctuations in weight; no difficulty sleeping Integument: Skin is pale, warm, moist. No lesions observed Eyes: Pupils equal, round, and reactive to light. No discharge observed. Extraocular muscles intact. ENT: Right ear red in color, drainage from nose, throat unremarkable. Cough noted with phlegm production Neck: Unremarkable with no tracheal deviation, no decrease in ROM, no lymphadenopathy, goiter, or masses Chest: Equal chest rise and fall noted; retractions present Pulmonary: Shallow wheezing noted in upper lobes. Patient only able to speak in 4–5-word sentences, states nothing is helping him catch his breath BRG-SON NURS 217 Community Assignment Pediatric Health History Student Name: Kaitlyn Capro Cardiovascular: Tachycardic with a heart rate of 130 Gastrointestinal: Soft, non-tender, non-distended. Bowel sounds present. Last bowel movement 03/20/22. Genitourinary: Circumcised (per mom), decreased urine output since this morning. Gynecologic: N/A Musculoskeletal: Active ROM to all extremities. No deformities. Neurologic: Patient states he is getting tired. Endocrine: N/A VI. Family Medical History Chronic bronchitis, hypertension, anxiety – mother No medical history with father Grandparents – hypertension and high cholesterol in both grandmother and grandfather; diabetes in grandmother VII. Psychosocial History Child reports not liking school because “it is boring, and it takes too long” Child earns good grades in school but often must be redirected from talking to classmates during class times Socializes with family and peers well – sometimes has arguments with sibling; likes to spend time with mom and go fishing with dad Spends the weekends with grandparents by choice VIII. Sexual History N/A IX. Family History a. Family Composition: Two-parent married family with two children. b. Home and community environment: Single family home with two cats. Cats remain inside. Electric heating, electric appliances, public water supply. All functioning Smoke and carbon monoxide detectors in place Pest control in place – mom reports no trouble with roaches, rats, or bedbugs BRG-SON NURS 217 Community Assignment Pediatric Health History Student Name: Kaitlyn Capro Fresh fruit and veggies used; meats are frozen until needed All medications/cleaning supplies locked in cabinet; lighting/night lights throughout home Mom states there is no smoking allowed in the house. Family does not have a formal fire escape plan No soiling observed in every area of the home; every bedroom with a bed; child watched by an adult while in the bathtub Active construction site right outside of the home c. Occupation and education of family members: Mother – employed full-time as an LPN at a local nursing home Father – employed full- time as an electrician Sibling – 6 years old and going to the 2nd grade. Patient – 8 years old and going to the 3rd grade. d. Cultural and religious traditions: Family is non-denominational. Mother reports attending church regularly in the past, however due to COVID-19, the family prefers to tune in online for church services. e. Family function and relationships: Social interaction is evident among family members Family can meet the economic demands of normal life events and illness Education of the family members is adequate to allow members to solve or comprehend most problems Medical care is available through the family’s local pediatrician/primary care provider. I. Nutritional Assessment a. Dietary intake: Mother usually does the grocery shopping No concerns related to the child’s eating habits and no special diet required related to their health. Three meals per day (+) snacks for school days child eats breakfast at school and family makes breakfast at home during the weekends. Lunches alternate between packed lunches from home and lunch at school. Dinner is prepared daily – choice of meals depends on the family’s schedule each day. Child prefers junk food for snacks – to which mother reports trying to create more healthier decisions. Fresh vegetables served with lunch and dinner each day – child is not picky and usually eats what he can Child prefers sodas and fruit juices often – mother states it is difficult to get the child to drink more water. Family usually eats dinner at the kitchen table, but sometimes prefer to relax and watch TV during dinner time. b. Clinical examination: BRG-SON NURS 217 Community Assignment Pediatric Health History Student Name: Kaitlyn Capro Normal weight gain, growth velocity, and head growth for age and gender Skin smooth, slightly dry, color pale but usually pinkish in color Hair silky, strong, elastic Thyroid not visible, palpable in midline Eyes clear, bright; conjunctiva pink, glossy Gums and mucous membranes pink, moist Heart rate – tachycardic d/t illness Normal bowel habits. Muscles firm, well-developed, equal strength bilaterally. Extremities symmetric; legs straight; joints flexible, full ROM, no pain or stiffness. Alert, responsive, emotionally stable; steady gait; reflexes intact. Playing It Safe Eating Well, Being Active NUTRITION AND PHYSICAL ACTIVITY SCHOOL Doing Well at School DEVELOPMENT AND MENTAL HEALTH Bright Futures Patient Handout 7 and 8 Year Visits Handling Feelings ORAL HEALTH SAFETY Healthy Teeth The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Original document included as part of Bright Futures Tool and Resource Kit. Copyright © 2010 American Academy of Pediatrics. All Rights Reserved. The American Academy of Pediatrics does not review or endorse any modifications made to this document and in no event shall the AAP be liable for any such changes. PAGE 1 OF 1 Bright Futures Parent Handout 7 and 8 Year Visits Here are some suggestions from Bright Futures experts that may be of value to your family. School SAFETY SCHOOL NUTRITION AND PHYSICAL ACTIVITY Staying Healthy Your Growing Child DEVELOPMENT AND MENTAL HEALTH SAFETY Safety ORAL HEALTH Healthy Teeth The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Original document included as part of Bright Futures Tool and Resource Kit. Copyright © 2010 American Academy of Pediatrics. All Rights Reserved. The American Academy of Pediatrics does not review or endorse any modifications made to this document and in no event shall the AAP be liable for any such changes. PAGE 1 OF 1
