Patient Information Name – T.C. Age – 2 years. Gender – female. Subjective
Chief Complaint: “Runny nose, cough, and fever.”
HPI: The 2-year-old female was brought to the clinic by her mother with complaints of runny nose, cough, and fever. She reported that the disorder started three ag...
HPI: The 2-year-old female was brought to the clinic by her mother with complaints of runny
nose, cough, and fever. She reported that the disorder started three ago, but the fever began a day
ago. She reports that the disorder is characterized by fussiness and decreased appetite. She
reports administering Tylenol every four, but the fever returned after about four hours.
Past Medical History: She denies hospitalizations. She says that the child met all developmental
milestones and is without disability.
Allergies: No known allergies.
Past Surgical History: No surgical history.
Medications: Tylenol
Family History: No family history of the present disorder.
Social History: Both parents are smokers. The child is in daycare, where several children are
sick.
Health maintenance: The child missed this season’s flu shot.
Review of Systems:
i. General: The child is generally fussy and crying.
ii. HEENT/neck: Runny nose
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