PATIENT HISTORY
Mother states: "My son has been having diarrhea and vomiting for 2 days."
Present Illness
"This is the first admission for this white male child, 4 years 2 months old, who was brought to the clinic by his mother with primary report of vomiting and diarrhea times 2 days. Client was in his usual state of health 3 days ago when he became irritable. Symptoms started 2 days prior to admission and oral intake has resulted in exacerbation of vomiting.
Patient Profile
4-year, 2-month-old male child. He lives with his mother, who is employed full time and is the child's legal guardian. He has no siblings and attends pre-school. No known allergies.
Past Medical History
40 week spontaneous vaginal delivery. Mother denies smoking, OTC medications, or ETOH during pregnancy. Mother's age at child's birth was 22. Breastfed for 5 weeks. As per mother child is a good eater and is very active. Toilet trained at 28 months but has had some accidents. Sleeps 9 hours each night. Treated in clinic at 26 weeks for otitis media. No adverse reaction to antibiotics No known food or environmental allergies. Immunizations are up to date. See clinic records.
Review of Symptoms
Developmental: Talks in 5-6 word sentences, maintains eye contact with conversation. Able to dress himself, able to hop on one foot and has a strong hand grasp. Able to draw a square with a pen.
Gastrointestinal: 2 days of diarrhea and vomiting. Unable to tolerate liquids. No solid food for 2 days.
Skin: Dry, mild diaper rash
Ear, nose, throat: No coouogh, runny nose, sneezing. Hearing intact.
Eyes: Sunken. No history of strabismus, no glasses.
Impression
4-year, 2-month old male child with no overt signs of developmental delay presenting with an acute onset of vomiting and diarrhea. Contributing factors unknown. Has a fungal infection in diaper area. Will admit for evaluation and treatment of dehydration.
No known food or environmental allergies. Immunizations up to date