Subjective data: Patient initials: LT Age: 20 months Gender: female…
Question Answered step-by-step Subjective data: Patient initials: LT Age: 20 months Gender: female… Subjective data:Patient initials: LTAge: 20 monthsGender: femaleEthnicity: CaucasianAllergies: NKDAInformant: motherLast Clinic Visit: 2 months ago for wellness check, and 9 days ago for sick visit with CC: fever and diarrheaParents/Living status: mother and father livingSiblings (age and gender): two older siblings, ages 10 and 6Family History: PGM with hypothyroidism and hyperlipidemia and CV disease (stent placement in her 50s)Past Medical History: chronic OM, hip click noted on first two well checks, bilateral hip radiographs negative and has not been noted furtherPast Hospitalizations/Injuries: PE tube placement 6 months agoDevelopment/School Issues: no developmental delaysActivities of Daily Living: no daycare, stays home with mom, activeImmunizations: currentCurrent medications: Tylenol and Motrin as needed for feversMom presents with patient today and is concerned as the patient has a 2-day history of fever. Temp max 103. Mom reports patient with loose stools for 11 days now, typically having 4-5 loose stools per day. Presented to the clinic approximately 8 days ago with fever and diarrhea for 3 days and subsequent rash. The rash was fairly extensive and noted on the patient’s face, legs and trunk. (MD note described the rash as blanching papules). Over the past week, the rash has cleared significantly and only remnants remain at this time. Denies scratching or itching. No topical agents have been applied. The previous fever lasted for 3 days and stopped. The patient is here today with a 2-day history of fever, and mom is concerned as the patient has had a significant decrease in appetite and PO intake in general. One wet diaper today (4:00pm). Mom states the child will cling at times and at other times be inconsolable. Also reports patient seems “sluggish and drowsy,” especially with high fevers. Mom states, “She’s just not been herself for what seems like a long time now.” Poor sleep the past 2 nights. No one sick at home, although both siblings have started back to school in the past 2 weeks. Mom is primarily concerned about the loose stools, fever, and poor PO intake. Denies history of vomiting. Rare cough, minimal congestion.Objective data:Weight: 24 lbs.T: 102.5HR: 120RR: 24General appearance: fussy at times during exam, though smiling at examiner at times as well. Nontoxic appearing.Skin: faint, scattered papules to face, trunk, and back, + blanchingHead: symmetricalEyes: + red light reflex, no drainageEars: bilateral PE tubes intact and patentNose: bilateral nares essentially clear, scant clear nasal drainage notedMouth/Throat: free of erythema or exudateNeck: supple, no LADChest and Lungs: Clear to auscultation bilaterally (CTAB) without wheezingHeart: RRR without murmurs or gallopsAbdomen: soft, +BS, no hepatosplenomegalyMusculoskeletal: MAENeuro: good tone, fussy at timesWhat is the diagnosis.Provide rational for this diagnosisProvide the differential diagnosis Health Science Science Nursing NURSUNG NSG 6430 Share QuestionEmailCopy link Comments (0)
