NR602 Discussion Week 3 part 2
| Physical Examination Riley
Vital signs: height: 85 centimeters, weight: 13 kilograms, B/P: 90/54, T: 99.5, HR: 118 BMP/reg., Resp: 28, reg, non-labored, SpO2: 95% General: somewhat lethargic and cries some throughout exam. SKIN: red, diffuse rash to the torso and abdomen. HEENT: Head normocephalic atraumiatic. Conjuctiva clear, non-icteric, but mildly injected PERRL. Unable to complete fundoscopic exam. Tympanic membranes intact with scant clear fluid posteriorly bil and mild injection. EAC unremarkable. Pinna/tragus w/o tenderness. Nares patent, mucosa mildly injected, sl. edema in inferior and medial turbinates bil, moderate clear to milky rhinorrhea. Pharynx with mild slight erythema, tonsils 2/4 bil. Oral exam unremarkable. Neck supple w/mild anterior cervical lymphadenopathy bil. Thyroid small, firm, equal bil. CARDIOPULMONARY: Heart RRR w/o murmur. Lungs with mild expiratory wheeze throughout and barking cough noted occasionally throughout examination. Respirations even an |
20:08 |
| and unlabored. Abdomen rounded normoactive bowel sounds throughout, soft, non-tender, no masses or organomegaly.
Lab: WBC 9.0, Lymph 42%, Monocytes 7%, Neutrophils 50%, Eosinophils 2%, Hgb 13%, Hct 40 Discussion Questions Part Two: After reviewing the physical exam. What were your ‘red flags’ on physical exam? What are your primary, secondary, and differential diagnoses now? What are your priority actions in developing a plan for a child who is ill? * Remember to include your evidence-based reference for your rational. As you consider fever as a symptom this child had and fever as a common symptom in children also answer: What further diagnostic work-up should always occur with any child who presents with fever for longer than four days duration or higher than 104 without a clear cause? What are priority differentials to confirm or exclude on a child who has a fever for longer than four days duration or higher than 104 without a clear cause? |
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