Health History

ByPlatinum Essays

You will take on the role of a clinician who is building a health history for the following cases 

Chief Complaint:  A 11-year-old female patient complains of red left eye and edematous eyelids. Her mother states the child complains of “sand in my left eye.” 

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Subjective: Patient noticed redness three days ago. Denies having any allergies. Symptoms have gotten worse since she noticed having the problem.  

Vital Signs:  (T) 98.2°F; (RR) 18; (HR) 78; BP 128/82; SpO2 96% room air; weight 110 lb.

General: well-developed, healthy, 11 years old   

HEENT:  EYES: very red sclera with dried, crusty exudates; unable to open eyes in the morning with the left being worse than the right 

Skin: CTA AP&L

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