History of Present Illness - Nursing Assignment Help

Assignment Task:

History of present illness 

 Your patient is 8 years old X. His mother tells you that X began with mild upper respiratory symptoms which began 5 days ago. He had sneezing, mild sore throat, and non-productive cough. The sneezing and cough have stopped. Today, he developed a fever and is complaining of right ear pain. 

Medical history 

 X has been a healthy child with no chronic illnesses to report. He takes no medication except an over-the-counter vitamin once per day. His mother reports that he did not receive his last MMR vaccine prior to entry to school because she forgot. All other vaccines are current. X is an appropriate height and weight for his age. 

Social history 

 X is in 3rd grade and does well in school. He has many friends. He lives with his mother, father and 2-year-old sister who is also healthy. X’s diet is varied and appropriate. There have been no illnesses in other family members and no recent travel.

Review of Systems

• EENT – pain R ear
• All other systems WNL

Instructions

Introduce the patient so the reader understands the situation. 

What is your diagnosis? Document how you arrived at that diagnosis (i.e. what signs and symptoms lead you to the diagnosis?) with support from literature

What is your treatment plan? Include drugs (prescription and over-the-counter that you recommend), comfort measures, plans to follow up. Support your choices with a citation from literature.

Write a brief statement about any medications you are going to use including their action, site of action, half-life (if known), metabolism, excretion, and potential side effects. Cite support from literature

Write the patient education – What information is it important for the patient and/or the mother to know?

Use good grammar and spelling. Write in complete sentences (even if you use bullet points). Place citations and a reference page incorrect Harvard citation style. Include a cover page and reference page. You can complete the content in 1-2 written pages (does not include the cover page and reference page). 

Review the rubric to make sure you have covered all the important details.

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