History of Present Illness

Caso Clínico hipotético #10

 

Date: 02/18/22

Time: 14:35

Chief Complaint:

Colics and rhochis

 

Source: Family

Accompanied by:: Mother and father

DX : BRONCHIOLITIS

– History of Present Illness

HPI:

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. 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

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