CASO ·3 LUCAS ENRIQUE
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National University College-Bayamon *
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Subject
Health Science
Date
Nov 24, 2024
Type
Pages
7
Uploaded by EarlElectron7973
Bayamon Community College
17 Calle Maceo
Bayamon, PR, 00961
Tel.
Patient Name: Lucas Enrique Padilla Nieves
Record:03-NPN
Date: 11/28/2023
DOB: 2/24/2019
Age: 4.76
BCC XVIII
ENCOUNTER REPORT
SUBJECTIVE
Chief Complaint
Lucas Enrique Padilla Nieves is a 4 years old male. The reason for his visit is
GENERAL DISCOMFORT. Patient refers complaints of: FEVER AND GENERAL
DISCOMFORT with severity: Moderate. The patient indicates that from 1 to 10 his pain
is: Hurts even more 6 and refers that his pain/complaint occurred since 1 days.
Vital Signs
Vital Signs (2023-11-28)
OBSERVATION
VALUE
Blood Pressure - Sitting
119/74
Weight
63 lbs
Height
3' 10'' / 117 [in_i]
BMI
20.93 kg/m2
BMI percentile
297.73 kg/m2
BMI Category
Normal weight
BSA
0.9 m2
Heart Rate (Pulse)
96 /min
Resp. rate
17 /min
Temperature
39.48 Cel
Pain Scale
No hurt 0
Oxygen saturation
99 %
Inhaled oxygen
0 %
Blood Group
Not specified
Notes
Notes
Family History
RELATIONSHIP
CONDITION
DECEASED
GENDER
Mother
Hypothyroidism, unspecified
Female
Surgery Hx
STATUS
PROCEDURE
MODIFIERS
PERFORMED ON
COMPLETED
Acute tonsillitis
11/28/2023
Social History
Current occupation
: STUDENT
Living situation
: Lives with parents
Bayamon Community College
17 Calle Maceo
Bayamon, PR, 00961
Tel.
Patient Name: Lucas Enrique Padilla Nieves
Record:03-NPN
Date: 11/28/2023
DOB: 2/24/2019
Age: 4.76
BCC XVIII
Lifestyle Behavior
Smoking status
-
Smoking Status
: Never smoker
Drugs
-
History of use
: Has never taken drugs
Fragility Evaluation
Other Findings
: N/A
Active Diagnostics
NO PREVIOUS CONDITIONS HISTORY
Hospitalization
N/A
Immunizations
STATUS
VACCINE
CODE
DATE
SITE
DOSE
REACTION
LOT_NUM
MANUFACTURER
COMPLETED
Dtap-Hep B-IPV
110
11/28/2023
Obstetric History
Obstetric History
-
Grava
: N/A
Allergies
STATUS
CAUSED BY
CRITICALITY
REACTION
SEVERITY
IDENTIFIED
CATEGORY
ACTIVE
Other penicillins (product)
EDEMA (FINDING)
11/28/2023
medication
ADL
Bathing
: some asssistance needed
Dressing
: requires no assistance
Eating
: requires no
assistance
Toileting
: requires no assistance
Active Medications
No previous Medications history
PHQ9
Little interest of pleasure in doing things
: Not at all
Feeling down, depressed or hopeless
: Not at
all
Trouble concentrating (reading the newspaper or watching television)
: Not at all
PHQ 9 Result
Total
: 0 p
OBJECTIVE
Gynecologic Evaluation
Bayamon Community College
17 Calle Maceo
Bayamon, PR, 00961
Tel.
Patient Name: Lucas Enrique Padilla Nieves
Record:03-NPN
Date: 11/28/2023
DOB: 2/24/2019
Age: 4.76
BCC XVIII
General
: N/A
Laboratory Results
Chief Complaint (2023-11-28)
OBSERVATION
VALUE
Reason for visit
GENERAL DISCOMFORT
Chief Complaint
FEVER AND GENERAL DISCOMFORT
Pain Scale
Hurts even more 6
Duration of symptoms
1 days
Severity
Moderate
Vital Signs (2023-11-28) /tr>
OBSERVATION
VALUE
Blood Pressure - Sitting
119/74
Weight
63 lbs
Height
3' 10'' / 117 [in_i]
BMI
20.93 kg/m2
BMI percentile
297.73 kg/m2
BMI Category
Normal weight
BSA
0.9 m2
Heart Rate (Pulse)
96 /min
Resp. rate
17 /min
Temperature
39.48 Cel
Pain Scale
No hurt 0
Oxygen saturation
99 %
Inhaled oxygen
0 %
Blood Group
Not specified
Notes
Notes
Social History (2023-11-28)
OBSERVATION
VALUE
Patient is currently employed
false
Patient is currently unemployed
false
Patient is currently retired
false
Current occupation
STUDENT
Living situation
Lives with parents
Smoking status (2023-11-28)
OBSERVATION
VALUE
Smoking Status
Never smoker
Alcohol (2023-11-28)
OBSERVATION
VALUE
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Bayamon Community College
17 Calle Maceo
Bayamon, PR, 00961
Tel.
Patient Name: Lucas Enrique Padilla Nieves
Record:03-NPN
Date: 11/28/2023
DOB: 2/24/2019
Age: 4.76
BCC XVIII
Drinks Alcohol (finding)
false
Drugs (2023-11-28)
OBSERVATION
VALUE
History of use
Has never taken drugs
Fragility (2023-11-28)
OBSERVATION
VALUE
Hx of Falling
false
Dependence on Respiratory (ventilator)
status
false
Dependence on Wheelchair
false
Dependence on Supplemental Oxygen
false
Other Findings
N/A
Obstetric History (2023-11-28)
OBSERVATION
VALUE
Grava
N/A
ADL (2023-11-28)
OBSERVATION
VALUE
Bathing
some asssistance needed
Dressing
requires no assistance
Eating
requires no assistance
Toileting
requires no assistance
General (2023-11-28)
OBSERVATION
VALUE
Findings
FEVER 39.8
Ears, Nose & Throat (2023-11-28)
OBSERVATION
VALUE
No abnormal findings
false
Abdomen (2023-11-28)
OBSERVATION
VALUE
No abnormal findings
false
Findings
TENDERNESS, ABDOMINAL PAIN
Bayamon Community College
17 Calle Maceo
Bayamon, PR, 00961
Tel.
Patient Name: Lucas Enrique Padilla Nieves
Record:03-NPN
Date: 11/28/2023
DOB: 2/24/2019
Age: 4.76
BCC XVIII
PHQ 9 (2023-11-28)
OBSERVATION
VALUE
Little interest of pleasure in doing
things
Not at all
Feeling down, depressed or hopeless
Not at all
Trouble concentrating (reading the newspaper
or watching television)
Not at all
PHQ 9 Result Total
0 p
General (2023-11-28)
OBSERVATION
VALUE
No abnormal findings
false
Findings
FEVER, RUNNY NOSE
Abdomen (2023-11-28)
OBSERVATION
VALUE
No abnormal findings
false
Findings
TENDERNESS AND ABDOMINAL PAIN
Gynecologic Evaluation (2023-11-28)
OBSERVATION
VALUE
General
N/A
Neck (EVAL)
false
Respiratory/Chest (EVAL)
false
Heart (EVAL)
false
Right Breast (EVAL)
false
Left Breast (EVAL)
false
Abdomen (EVAL)
false
Pelvic Exam (EVAL)
false
false
Vagina (EVAL)
false
Cervical (EVAL)
false
Adnexal (EVAL)
false
Uterus (EVAL)
false
Rectal (EVAL)
false
Foot Exam (2023-11-28)
VALUE
OBSERVATION
false
Low risk: Mark all of the following
false
false
Bayamon Community College
17 Calle Maceo
Bayamon, PR, 00961
Tel.
Patient Name: Lucas Enrique Padilla Nieves
Record:03-NPN
Date: 11/28/2023
DOB: 2/24/2019
Age: 4.76
BCC XVIII
false
false
false
High Risk: Mark one or more of the
following
false
false
false
CBC (2023-11-07)
STATUS
OBSERVATION
VALUE
RANGE
NORMAL
Hemoglobin
12.1 g/dL
-
NORMAL
HCT
38.3 %
-
Plan (2023-11-28)
VALUE
OBSERVATION
false
Plan
DESCANSO EN EL HOGAR, DEBE TOMAR MUCHO
LIQUIDO, NO COMER ALIMENTO IRRITANTES, NI
GRASAS. SE RECOMIENDA CHILDRENS TYLENOL
PARA LA FIEBRE CADA 4 HORAS. DE SEGUIR
CON LOS SINTOMAS DEBE REGRESAR EN 3 DIAS.
ASSESSMENT
Dx
STATUS
DIAGNOSTIC
SEVERITY
TYPE
CODE
ONSET
ACTIVE
Other specified noninfective gastroenteritis
and colitis
None
Not Specified
K52.89
11/28/2023
ACTIVE
Other viral agents as the cause of diseases
classified elsewhere
None
Not Specified
B97.89
11/28/2023
ACTIVE
Fever, unspecified
None
Not Specified
R50.9
11/28/2023
ORDERS
Prescription
STATUS
SENT
TITLE/FORMULATION
FORMULATION
DURATION
REFILL
SIG
DISPENSE
SUBSTITUTION
ALLOWED
SIGNED
BY
PHARMACY
CODE
DISPEN
INFORMA
ACTIVE
False
Bentyl Bentyl 10 mg/5
mL oral syrup
Bentyl 10 mg/5
mL oral syrup
5 days
0
2 CC
NY
ORAL
ROUTE
EVERY
8
HOURS
PRN
120
Milliliter
True
5113
Duration: 5
Amount:
Millilit
Refill:
Substitut
Allowe
Immunization Orders
STATUS
CODE
VACCINE
PATIENT INSTRUCTIONS
QUANTITY
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Bayamon Community College
17 Calle Maceo
Bayamon, PR, 00961
Tel.
Patient Name: Lucas Enrique Padilla Nieves
Record:03-NPN
Date: 11/28/2023
DOB: 2/24/2019
Age: 4.76
BCC XVIII
ACTIVE
141
Influenza, Seasonal, Injectable
1
PLAN
Plan
Plan
•
Plan
: DESCANSO EN EL HOGAR, DEBE TOMAR MUCHO LIQUIDO, NO COMER
ALIMENTO IRRITANTES, NI GRASAS. SE RECOMIENDA CHILDRENS TYLENOL
PARA LA FIEBRE CADA 4 HORAS. DE SEGUIR CON LOS SINTOMAS DEBE
REGRESAR EN 3 DIAS.
Follow Up
Paciente se cita en un (a): 3 DIAS DE SER NECESARIO
EVALUATION AND MANAGEMENT
Evaluation and Management Code
DESCRIPTION
CODE
QUANTITY
DIAGNOSTICS
MODIFIERS
OTHER
OFFICE/OUTPATIENT NEW LOW MDM 30-44
MINUTES
99203
1
K52.89,B97.89,R50.9
N/A