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You are seeing a 3-year-old Hispanic male brought into the office today by his mother for c/o upper respiratory illness and decreased oral intake. His mom is a 16-year-old single mom. You note that he was in the office 1 month ago for his well-child check and at that visit he had a cough, rhinorrhea and some faint expiratory wheezing was heard but no respiratory distress. He required no treatment for this. He was plotted appropriately on the growth curve at the 75 % for age. He had some periorbital edema, no drainage and no scleral injection noted. He was ordered cetirizine daily at that visit for environmental allergies. Mom reports giving cetirizine daily since that visit. Today in the office his vitals are as follows: Wt 19kg HT 75 cm Temp 38.2 HR 140 Respirations 48 BP 138/94 He has allergies to amoxicillin, peanuts and his mother feels he has seasonal allergies as well. She feels that he has frequent episodes of coughing and sneezing. He continues to take the cetirizine daily as ordered. Mom noted that he started this week with a runny nose with clear thin secretions. Per mom last week she struggled to get him to
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HEALTH SCIENCE
NURSING

 
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