Allergies/Adverse Reactions Thesis
Allergies/Adverse Reactions Thesis
Accompanied by:: Mother and father
DX : BRONCHIOLITIS
– History of Present Illness
HPI:
The patient is a 1m 2d old male, birth history of cesarean section delivery at 39 weeks, no PMHx/surgery, no allergies, vaccines up to date, no pets, who is brought to the hospital because of colics and irritability, onset 2 weeks ago, worsening in the last 5 days, described as intermittent, associated with difficulty breathing and rhonchi sounds, worse at night, no aggravating or alleviating factors. The mother denies ear pain/discharge, nasal congestion, cough, vomiting, diarrhea, recent trauma/falls, loss of consciousness, or contact with sick relatives.
– Allergies
Allergies/Adverse Reactions:
Allergy/AdvReac Type Severity Reaction Status Date / Time
No Known Allergies Allergy Verified 02/18/22 10:0
Medication Instructions Recorded Confirmed Type
Unknown [No Known Home Meds] 02/18/22 02/18/22 History
– Travel Risk – Coronavirus
Travel Risk: No
Contact Risk: No
Has patient experienced symptoms?: No
Symptoms experienced: Cough
Past Medical History
– Information
Attestation statement: The following information was validated with the patient or family.
Source: Obtained From Family
– Past Medical History
Duration of Pregnancy: 39 weeks
Type of Delivery: Cesarean section
Complications: No
Neonatal Complications: No
Regular Diet: Yes
Hospitalized: No
Accident: No
Complete Vaccination: No (up to date)
Blood Transfusion History: No
Medical History: No Medical History
– Psycomotor Development
Psycomotor Development: No: Turn, Crawl, Sit Down, Stand Up, Walk, First Words, Teeth
Family Medical History: No Significant Medical Family history
– Measurement
Vital Signs:
Last Vital Signs
Temp 37.1 C 02/18/22 09:34
Pulse 157 02/18/22 09:34
Resp 48 02/18/22 09:34
BP 87/55 H 02/18/22 09:34
Pulse Ox 99 02/18/22 09:34
Height & Weight:
Height 22.83 in
Weight 4.99 kg
