NR 602 SOAP Note -Riley’s Fever and Rash

NR 602 SOAP Note -Riley’s Fever and Rash

NR 602 SOAP Note -Riley’s Fever and Rash

1. F., 17 months, M, Latino: CPT Code: 99214?

S.

CC- Fever and rash

HPI- Riley is brought in today for a complaint of fever and rash. The fever began 3 days ago and is of normal levels in the morning then gets as high as 103 to 104 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 dry 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, but is not really eating much and is not playing.

Medications- Mother is giving OTC Robitussin cough and cold at 1 tsp last night and this morning.  Liquid Tylenol ½ a tsp last night and this morning.

Immunizations- Birth – Hep B, 2 months – Hep B, DTaP, HIB (COMVAX), PCV13, IPV, 4 months – DTaP, HIB (COMVAX), PCV13, IPV, 6 months DTaP, IPV, 6 months – DtaP, PCV 13, IPV, Hep B

Allergies- Seasonal allergies (per mother)

PMH- Born at 34 weeks gestation via cesarean section, weight. 5lb 1 oz. The mother developed preeclampsia and gestational diabetes. The mother quit smoking when she found out she was pregnant. Riley has allergies per mother.

Social history- Lives with mother and maternal grandparents for the past 8 weeks. Their father is involved but lives 2 hours away in the state capital where he works.

Family history- They are maternal and paternal smokers. The mother has been one since age 22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no diseases reported in either parent. Mother has a history with gestational diabetes and preeclampsia.  MGM has a history of hyperlipidemia, Type 2 DM, and Hypertension. They are Latin American in descent, emigrated from Cuba in the 1970s. MGF has a history of hypertension, hyperlipidemia, and an MI with stenting 2 years ago.  The mother has two siblings; one who died in an MVA 5 years ago at the age of 18 a younger brother, and an older sister who is 42 and lives in a large urban city in the Midwest with her family, and she is in good health. Other family members died of old age. She is unaware of paternal familial health history.

ROS-

Constitutional- fever x 3 days with some lethargy.

 

HEENT- clear rhinorrhea.

 

Skin- in the last 24 hours he has developed a red, diffuse rash to the torso and abdomen that does not itch.

 

Respiratory- he has developed a dry cough in the past day.

 

Gastrointestinal- Not reported

 

Genitourinary-  Not reported

 

Neurological- Not reported

 

Musculoskeletal- Not reported

 

Hematological- Not reported

 

Lymphatics- Not reported

 

O.

Physical Exam:

V/S:  Height: 81 cm (31.89 in), Weight: 13 kg (28.66 lbs), B/P: 94/60, T: 100.6, HR: 114 BMP/reg., Resp: 28, reg, non-labored, SpO2: 97%

17 months old, Height 51st percentile, Weight 87th percentile (CDC, 2016)

GENERAL: somewhat lethargic and cries some throughout exam.

SKIN: Diffuse erythemamtous rash in fine popular patches across the torso and very erythematous to the cheeks.

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 with sl. edema to the inferior and medial turbinates bil, moderate clear 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 in posterior bases. Respirations even and unlabored.

ABDOMEN: rounded normoactive bowel sounds throughout, soft, non-tender, no masses or organomegaly.

Lab: WBC 6.9, Lymph 50%, Neutrophils 40%, Monocytes 6%, Eosinophils 3%

A.

Primary-

Roseola (B08.20)–

 

Secondary-

Upper Respiratory Infection (J06.9)-

Differential diagnosis-

Dehydration (E86.0) – Riley has had an intermittent fever …

 

Diagnostics-

 

Tests to be performed include CBC …

 

Contact the doctor if:

-Your child’s rash gets worse.

-Symptoms (such as a fever, a general feeling of illness, or signs of infection) are severe or become worse.

-Symptoms become so uncomfortable that your child cannot tolerate them.

-A new rash continues longer than 1 week.

-A rash that has been previously diagnosed continues longer than 4 weeks or is not following the expected course.

-Your child’s symptoms become more severe or more frequent.

(Hay, Levin, Deterding, & Abzug, 2014).

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References

AAP.org. (2016) Medications used to treat fever.  Retrieved from https://www.healthychildren.org/English/health-issues/conditions/fever/Pages/Medications-Used-to-Treat-Fever.aspx

American Academy of Pediatrics (AAP). (2015). Allergy Tips. Retrieved from https://www.aap.org/en-us/about-the-aap/aap-press-room/news-features-and-safety-tips/pages/allergy-tips.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR:+No+local+token

Arnold, D. H., Moore, P. E., Abramo, T. J., & Hartert, T. V. (2011). The Dilemma of Albuterol Dosing for Acute Asthma Exacerbations in Pediatric Patients. Chest, 139(2), 472. http://doi.org/10.1378/chest.10-2163

CDC. (2016). Scarlet Fever: A Group A Streptococcal Infection. Retrieved from http://www.cdc.gov/features/scarletfever/.

Fenstermacher, K. & Hundson, B. T. (2016). Practice Guidelines for Family Nurse Practitioners (4th ed.). St. Louis, MO: Elsevier.

General Health/Well Child Checkups. (n.d.). Retrieved January 22, 2017, from http://www.pierremontpediatrics.com/Health-Information-and-Education-Resources/General-Health-Well-Child-Checkups/18-months-old.aspx

Hamilton, J. L. & John, S. P. (2013, February 15). Evaluation of fever in infants and young children. American Family Physician, 87(4), 254-260.

Hay, W., Levin, M., Deterding, R., & Abzug, M. (2014). Current diagnosis and treatment: Pediatrics (22nd ed.).

Lowry, J. & Leeder, J. (2015). Over the counter medications: Update on cough and cold preparations. Pediatrics in Review, 36(7), 286-298.

Mayo Clinic. (2016). Roseola Symptoms. Retrieved from http://www.mayoclinic.org/diseases-conditions/roseola/basics/symptoms/con-2002351.

National Institute for Health and Care Excellence (NICE). (2013). Feverish illness in children. Retrieved from http://guidance.nice.org.uk/CG160.

Stiehm, R., Wood, R., Kaplan, S. & TePas, E. (2016). Approach to the child with recurrent infections. Retrieved from http://www.uptodate.com/contents/approach-to-the-child-with-recurrent-infections.