NR602 week 3 soap note

Child with Fever and Respiratory or Skin issues

Kayla brings Riley, now 18 months, in for complaint of fever
and rash. The fever began 3 days ago and is of normal levels in the morning
then gets as high as 100 to 101 degrees in the afternoons. Riley has also had
clear rhinorrhea and in the last 24 hours he has developed a red, diffuse rash
to the torso and abdomen that does not itch and a barking cough in the last
day. Mother reports he is drinking, but not as well as usual. He did have a good
wet diaper this morning and at least four diapers yesterday, but is not really
eating much and is not playing.

Medications: Mother has stopped the Zyrtec. She is giving
Robitussin cough and cold at 2.5 ml last night and this morning. Liquid Tylenol
7.5 ml last night and this morning.

She is very concerned about the level of the fever and the
fact that after 3 days he is not improving.

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

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