Social History: The patient happily lives with both parents and two siblings (one brother and one sister) in a house. The parents do not smoke. They do not have any pets. Patient does not go to day care and there is no one else sick at home
Erickson’s Stage: Autonomy vs Shame and Doubt
• This stage focuses on the child becoming independence and making their own choice. The patient is successfully completing this stage a s evidence by, patient walking away from mother and father to pick up a toy.
Review of Systems:
• General: Patient does not have fever, chills, or dizziness. No weight changes. Admit to mild fatigue. Denies recent travel
• HEENT: Denies head trauma. Denies red eye or eye discharge. Denies ear problems, No earache/pulling or ear discharge. No nasal discharge or nasal congestion. Denies loss of appetite, sore throat or pain when swallowing
• …show more content…
There is no reduction in urine output
• Musculoskeletal: Report weakness,
• Skin: denies rash, itching or lesion
• Neurological: Denies headache, report fatigue
• Hemodynamic: Denies anemia, clotting or bleeding tendencies
• Endocrine: Denies thyroid disorders
• Psychosocial: Denies any change in mood or mentation. She is in good mood most of the time Denies thought of self-harm or others
Objective Data
General Appearance: The patient is a 2-year-olf African American female who is alert and oriented, well hydrated, cooperative and in no apparent distress
Vital Signs:
• HR: 126/min
• Temp: 97.8F
• Resp: 35/min
• Height:37 inches
• Weight: 15.45kg – 34lbs, 93.85% tile
• BMI: 17.5 84% tile
Physical Exam:
• Eyes: Eyes is normal. No redness or discharge, no lesion
• Ears: Tympanic membrane is clear, intact and normal. Light reflex is
Erickson’s Stage: Autonomy vs Shame and Doubt
• This stage focuses on the child becoming independence and making their own choice. The patient is successfully completing this stage a s evidence by, patient walking away from mother and father to pick up a toy.
Review of Systems:
• General: Patient does not have fever, chills, or dizziness. No weight changes. Admit to mild fatigue. Denies recent travel
• HEENT: Denies head trauma. Denies red eye or eye discharge. Denies ear problems, No earache/pulling or ear discharge. No nasal discharge or nasal congestion. Denies loss of appetite, sore throat or pain when swallowing
• …show more content…
There is no reduction in urine output
• Musculoskeletal: Report weakness,
• Skin: denies rash, itching or lesion
• Neurological: Denies headache, report fatigue
• Hemodynamic: Denies anemia, clotting or bleeding tendencies
• Endocrine: Denies thyroid disorders
• Psychosocial: Denies any change in mood or mentation. She is in good mood most of the time Denies thought of self-harm or others
Objective Data
General Appearance: The patient is a 2-year-olf African American female who is alert and oriented, well hydrated, cooperative and in no apparent distress
Vital Signs:
• HR: 126/min
• Temp: 97.8F
• Resp: 35/min
• Height:37 inches
• Weight: 15.45kg – 34lbs, 93.85% tile
• BMI: 17.5 84% tile
Physical Exam:
• Eyes: Eyes is normal. No redness or discharge, no lesion
• Ears: Tympanic membrane is clear, intact and normal. Light reflex is