Week 3 Assignment:Josephine BelmohWalden University NURS-6541N-1March 15, 2019
SUBJECTIVE DATA:Patient Initials: K.W Age: 11 years 2 months; Race: Caucasian; Gender: FemaleCHIEF COMPLAIN (CC):Mother states K.W complains of "right ear pain x 5 days."History of Present Illness ( HPI):K.W is a 12-year-old Caucasian female present in clinic with mother, complaint of right ear pain x five days with child pulling on the ear and irritable. Mother reports pain started while at home watching a movie. According to the patient's mother, pain has not radiated. K.W states pain is sharp with scale of 6/10 and constant and get worse with lying on the affected side and better when sitting up. Mother placed warm compresses and give K.W Ibuprofen for pain every 6 hourswith little relief. Mother stated temperature of 100 degree Fahrenheit and complain of the patient having occasional shortness of breath. Mother state the patient has a decrease in appetite since ear pain started. Mother report recent upper respiratory infection present for one week.Location: Right earQuality: K.W states with child pulling on the ear and constant.Severity: K.W stated a pain scale of 6/10 and sharpTiming: The symptoms started five days ago with child pulling on the ear and constant.Setting: K.W stated right ear pain started five days ago while watching a movie.Factors that Alleviates and aggravates pain: Better when sitting up and worse when lying on the affected side.Pain associating signs and symptoms: decrease appetite, upper respiratory infection, pulling on right ear.Past Medical History (PMH):Recurrent airway disease, No history of hospitalizations.MEDICATION AND DRUG/FOOD ALLIGIES:There are no known allergies reported by mother or patient.CURRENT MEDICATION:Patient is on Proventil HFA 2 puffs inhaled every 4-6 hours PRNfor the shortness of breath, Montelukast (singulair) 5 mg PO daily, albuterol sulfate 0.63 mg/3ml
inhalation nebulization solution every 4 hours for SOB or wheezing. Ibuprofen 5-10mg discontinue. Ibuprofen 10mg PO every 6 hours PRN.Immunization History:Patient states she is up to date with all vaccines including flu, pneumonia and tetanus vaccines.Childhood illness:respiratory problems, airway disease.INJURIES:NoneSEXUAL BEHAVIOR:The patient is not active with sex.PAST SURGICAL HISTORY (PSH):There are no surgical history for this patient reported by the mother.OB/GYN History:Mother states Patient is not menstruating at this time.SOCIAL HISTORY:The mother reports the patient is active, eats a variety of foods, the use of consistent seatbelt when in the car or vehicle, no tobacco use, no alcohol use. Mother states K.W play with other Kids well.FAMILY HISTORY:Mother age 35- has nasal allergies, maternal grandfather age 58- Liver disease, alcohol abuse, tonsils removal at age 30 — Maternal grandmother age 52- with gallbladder removal at age 45. Father status unknown. Unknown paternal grandfather. Patient has no sibling.
- Spring '19
- Otitis Externa