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