Pediatric Case Study CHIEF COMPLAINT Identifying Data/Source – from parent HISTORY OF PRESENT ILLNES

Pediatric Case Study CHIEF COMPLAINT Identifying Data/Source – from parent HISTORY OF PRESENT ILLNESS PAST MEDICAL AND SURGICAL HISTORY Prenatal/Birth/Neonatal History Growth/Development Surgical History Emergency/Trauma History Travel/Exposure History Medication, Allergies, and Adverse Reactions Pediatric Health Maintenance Nutrition/Diet Sleep Patterns Family History Social History REVIEW OF SYSTEMS General Skin Eyes Ears Nose Mouth/Throat Dental Neck Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal NeurologiC PHYSICAL EXAMINATION Vitals General Lymphatic Head Eyes Ears Nose Mouth/pharynx Neck Thorax/lungs Cardiovascular Abdomen Genitourinary Rectal Back Extremities Neurologic Mental Strength Reflexes “My baby has a fever and is fussy.” Nine month-old female accompanied by her mother and father. The mother is the primary caretaker, and both parents are reliable historians. M.N. is a nine-month old white female who 2 days prior to the admission (PTA) was noted to be more irritable, sleeping more, and have a decreased appetite. She felt a little warm, but no temperature was taken. One day PTA, child had four episodes of nonbilious, non-bloody emesis and further reduction in appetite. M.N. has continued to breast-feed regularly but has been uninterested in taking any solids. Early this morning, M.N.’s mother noted she was “hot” with a temperature of 1030 (axillary), and she had three more episodes of emesis overnight. She received acetominophen after the fever was discovered. Mother promptly brought the child to the clinic this a.m. M.N. has not had cough, runny nose, diarrhea, or known ill contacts. She only had one wet diaper yesterday, and her diaper was dry this a.m. Her weight was 8.6 kg at her nine-month-old well visit last week. M.N. was seen this a.m. in the clinic, where her peripheral WBC was 20,000 and her catheterized urinalysis was nitrate and leukocyte esterase positive with numerous WBCs and bacterial on microscopy. Serum chemistries were normal other than bicarbonate of 16. After initial antibiotic and fluid management of probable complicated urinary tract infection (urine culture pending) and moderate dehydration. Pregnancy was without complication or medical concerns, followed by a spontaneous vaginal delivery at 38+ weeks. Prenatal ultrasounds were normal by the parents’ report, including kidneys. The nursery course was notable only for mild physiologic jaundice never requiring phototherapy. The child otherwise had a normal nursery course. Metabolic disease screens normal. She has met all developmental milestones with head circumference, length, and weight tracking at the 50th percentile since birth. She is just beginning to pull to stand, feeds self cheerios, plays “peek-a-boo” and “babbles.” No surgical history. She has never been hospitalized, injured, or had an emergency room visit. She has had a couple of clinic visits for “cold” and one ear infection treated with amoxicillin approximately 2 months ago. No travel since birth and is not in day care. They have one pet dog. No known allergies or adverse reaction to foods or medications. She takes a multivitamin with iron daily. Her mother’s only medication is prenatal vitamins. M.N. has mad the 2 weeks, 2-, 4-, and 12-month well-baby visits, and her immunization are up-to-date per the medical record. Parents have safety locks on all cabinets with medications or poisons, with no concerns for a possible ingestion. Other than breastfeeding four times per day, she eat rice cereal, jarred baby food, vegetables and fruits, and is just starting some baby food with pureed meats. Typically sleeps through night other than last couple of days since she has been ill. Her family history is negative for chronic diseases on both sides. Mother denies having UTIs as a child. No family history of mental retardation, metabolic disease, or seizure disorders. No tobacco exposure. M.N. is an only child. Lives with parents, 26-year old father and 24-year-old mother. Describes stable and supportive family dynamics. Both parents have high school and some college education. Review of System See HPI for general appearance No rash, bumps or bruising of skin. Decreased tearing noted this morning by mother. No eye discharge or redness No tugging at the ear or discharge. Denies rhinorrhea or epistaxis. Denies hoarseness. Is afraid throat may be “sore” because of decreased appetite. Her two bottom teeth came in about one month ago. She has been moving her neck/head freely without apparent stiffness. Denies cool extremities or cyanosis. Denies cough, hemoptysis, phlegm, wheezing or stridor. See HPI for emesis. Denies diarrhea, constipation, changes in bowel habits, melena, hematochezia, change in stool caliber, or jaundice. Last bowel movement was this a.m. See HPI for decreases frequency. Diapered infant, however with out apparent dysuria, hematuria, or malodorous or discolored urine. No vaginal discharge. Denies joint swelling, limited range of motion, erythema. See HPI for irritability and increased sleepiness. However, oriented to parents, easily consoled, and vigorously resists examination. Physical Examination BP 92/60 P 130 R 32 T 102.50F (rectal), Ht 70 cm (50%) Wt 7.9 kg (25-50%) (700 g down from last week), Head Circumference 44 cm (50%) Well-developed, well-nourished infant who is fussy with examination, vigorously opposes attempted separation from parents and examination. Easily consoled by parent after examination. No lesions, rashes, petechiae. Normal to slightly reduced skin turgor. No palpable preauricular/postauricular/anterior cervical/posterior or cervical/supraclavicular/inguinal nodes. Normocephalic, anterior fontanelle is soft and flat. PERRLA, no conjunctival erythema or discharge. Tympanic membranes normal position, grey, normal mobility, translucent without effusions. Septum midline, with no friable, non-hemorrhagic mucosa and no exudates. Dry buccal and sublingual mucosa, no tonsil erythema or exudates, two lower incisors Full active and passive range of motion. Negative Brudzinski sign. No retractions, lungs clear to auscultation with no rhonchi, wheezing, or rales. Regular rate and rhythm, S1 and S2 normal with no murmur or gallop, femoral pulse are 2+/=, capillary refill=2 seconds. Active bowel sounds, no hepatosplenomegaly, difficult examination by not apparently tender when distracted. Normal female genitalia, no discharge or erythema, Tanner stage 1. Rectal: not performed Full active range of motion of all extremities. No cyanosis, clubbing or edema. Not cooperative but apparently normal strength in extremities. Reflexes: DTRs 2+ bilateral at Achilles, patellar, biceps, without clonus, upgoing toes.

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