NR 602 Pediatric Clinical Case Assignment

NR 602 Pediatric Clinical Case Assignment

NR 602 Pediatric Clinical Case Assignment

Pediatric Clinical Case Presentation

CC: cough and wheezing; follow-up from ER visit

HPI: Patient is a 6-month-old Caucasian male presenting in the office today as a follow-up to an emergency room visit last night. Mother of patient reported fever of 102 degrees accompanied by hearing wheezing and an increasing cough, therefore went to the emergency room. Patient received a Rocephin shot, one dose of oral steroid and a breathing treatment before being sent home from the emergency room. Mother reports patient did not sleep through the night, fever has resolved, but patient remains occasionally irritable with a wet cough and audible wheezing.

ROS (pertinent positives)

            General: reports history of fever yesterday and irritability per mother

HEENT: nasal congestion per mother

Resp: reported wheezing, intermittent cough per mother

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PE (pertinent positives)

Vital signs: T: 98.4 degrees, HR: 143 bpm, O2: 96% RA

Ht: 26in (23^rd percentile), Wt: 18lbs (53^rd percentile), BMI: 18.2, HC: 17in (45^th percentile)

General: alert, active, attentive, in no acute distress, afebrile

Neuro: moves all extremities well and good tone

HEENT: Normocephalic, fontanelle soft and flat. Eyes: round, equal, reactive to light, red reflex present. Ears: tympanic membranes pearly with good landmarks, pinna well-formed. Nose: patent.

CV: normal S1, S2 with regular rate and rhythm, femoral pulses palpable and equal bilaterally

Resp: wheezing on auscultation, intermittent cough

Abdomen: soft, bowel sound presents.

Musculoskeletal: All extremities normal active motion. Hips stable with normal active motion

Tanner Stage 1 – no signs of puberty. Scrotum, testes, and penis as in childhood

with no signs of public hair

Lab/Diagnostic Findings:

            Rapid Flu Test: negative

Rapid RSV Test: negative

CXR: mild lower lobe infiltrate

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