ELECTRONIC

HEALTH RECORD
ARMENA, SHANEN MARIE V.
BSN3
SCENARIO
THE MOTHER OF J.D.C. BROUGHT HER 4-YEAR-OLD SON TO THE PRIMARY CARE CLINIC
AFTER HE CAME DOWN WITH A FEVER 2 DAYS AGO. SHE SAID HE HAS SHAKING CHILLS,
A PRODUCTIVE COUGH, AND HE CAN'T LIE DOWN TO SLEEP BECAUSE “HE CAN'T STOP
COUGHING.” AFTER J.D.C. IS EXAMINED, HE IS DIAGNOSED WITH COMMUNITY-
ACQUIRED PNEUMONIA (CAP) AND ADMITTED TO YOUR FLOOR. THE INTERN IS BUSY AND
ASKS YOU TO COMPLETE YOUR ROUTINE ADMISSION ASSESSMENT AND CALL HER WITH
YOUR FINDINGS.

YOUR ASSESSMENT FINDINGS ARE AS FOLLOWS: VITAL SIGNS - T 40 DEGREES C (104

DEGREES F), PR 130,RR 40, BP 100/70, OXYGEN SATURATION 87% IN ROOM AIR. HIS
HEIGHT AND WEIGHT ARE IN THE 50TH PERCENTILE FOR HIS AGE. YOU AUSCULTATE
DECREASED BREATH SOUNDS IN THE LEFT LOWER LOBE ANTERIORLY
AND POSTERIORLY AND HEAR COARSE CRACKLES IN THE LEFT UPPER LOBE. HIS NAIL
BEDS ARE DUSKY ON FINGERS AND TOES. HE HAS A COUGH PRODUCTIVE OF RUST-
COLORED SPUTUM AND COMPLAINS OF PAIN IN THE LEFT SIDE OF HIS CHEST WHEN HE
COUGHS. J.D.C. SEEMS TO BE WELL-NOURISHED AND ADEQUATELY HYDRATED. HE HAS
NEVER GOTTEN THE PNEUMOVAX OR FLU SHOT. HE DOES REPORT GETTING “HIVES” WHEN
HE TOOK “AN ANTIBIOTIC PILL” A FEW YEARS AGO BUT DOESN'T REMEMBER THE NAME
OF THE ANTIBIOTIC
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