NR602 - Week 3 - Sick Child Clinical Case Presentation

NR602 - Week 3 - Sick Child Clinical Case Presentation

Patient Information:

J. T., 22 months, Male, Caucasian Subjective:

Chief Complaint: Fever and rash

HPI:

J. T. is a 22-month old Caucasian male who is brought in to the family practice office today by his mother for complaints of fever and rash. The mother reports that the fever started 3 days ago along with a runny nose and cough. She reports thefever has been as high as 103° F (rectal), and then would drop to 99° F after alternating Tylenol and Motrin. She states that she was not overly concerned about the fever initially because she was able to keep it under control with medications, and the child did not appear to betoo sick despite having a high fever. When she woke up this morning, she noticed a rash had developed on his chest and abdomenovernight,which is the main reason she brought him in to be evaluated.

Allergies: No known drug, food, or environmental allergies

Current Medications:Children’s Acetaminophen Suspension Liquid 160 mg/5 mL, 160 mg every 4-6 hours PRN for pain/fever; Children’s Motrin Suspension 100 mg/5 mL, 100 mg every 6-8 hours PRN for pain/fever.

Immunizations: Up-to-date

PMHx:RSV at 19 months, otitis media

PSHx: No past surgical history

Soc Hx:Lives with mother and father. Attends daycare 5 days per week due to parents work schedule. No other siblings or pets living within the household.

Fam Hx:Father:No PMHx; Mother: Gestational DM; Paternal Father:HTNandhyperlipidemia; Paternal Mother: NoPMHx; Maternal Father: HTN and Type 2 DM; Maternal Mother: No PMHx ROS:

CONSTITUTIONAL: Mother reports he has had a fever for the past 3 days,“playing as usual, but a little cranky”. She reports a decreased appetite; tolerating oral fluids and popsicles, but not drinking as much as he usually does.

SKIN: Mother reports rash developed on his chest and abdomen overnight, and has not noticed him itching.

HEENT: Mother reports he has had a runny nose with clear nasal drainage.

RESPIRATORY:Mother reports him having a “dry” cough and swollen glands.

GASTROINTESTINAL: Mother reports a decreased appetite. No vomiting or diarrhea.

GENITOURINARY: Mother reports adequate urine output with 4 wet diapers yesterday and 1 this morning.

Objective:

Physical Exam: