History

Chief Complaint

“My child is burning up and is complaining of belly pain!” 

History of Present Illness

Jimmy John is a 9 year old Hispanic male who presents at the Flint, MI Urgent Care with his mother. Patient’s mother reports that he had a sore throat three weeks ago which was dismissed as a viral infection and left untreated.  Mother reports that symptoms have persisted and worsened within the last two days. Jimmy John states that his whole body aches and he woke up last night with a nose bleed.

Past Medical History

• Asthma diagnosed age 5
• Childhood obesity age 3
• Pharyngitis age 9

Pertinent Family History

• Mother diagnosed with obesity, Type 2 Diabetes, and hypertension at age 40
• Father’s history unknown
• Younger brother, age 2, was born with atrial septal defect which was surgically corrected at birth
• Older sister is healthy at age 13

Pertinent Social History

• Lives in a two bedroom apartment with his mother and siblings in downtown Flint
• Goes to a private, Catholic school
• Hobbies include climbing trees and soccer

Allergies

• Seasonal (rhinorrhea and dry cough)

Medications

• Albuterol 200 mcg  inhalation capsules: 1 inhalation orally every 4 to 6 hours as needed for acute asthma exacerbation.

Focused Physical Examination

Skin

• Diaphoretic
• Hot on palpation
• Truncal rash

HEENT 

• Pharyngitis
• Lymphadenopathy

Musculoskeletal

• Malaise
• Arthralgia
• Polyarthritis

Cardiac

• Sinus tachycardia
• Friction rub on auscultation
• Murmur on auscultation

Gastrointestinal

• Nausea for the past two weeks
• Three episodes of emesis in past 48 hours
• Abdomen tender to palpation

Vital Signs

• Temp 102.5 F
• HR: 122
• BP: 125/64
• RR: 25
• SPO2: 94% on RA