PBL Case Study Discussion: Assessment of a Child Part One (graded)
Child with Fever and Respiratory or Skin Issues
Kayla brings Riley, now 17 months, in for complaint of fever and rash. The fever began “a couple of 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.
She is very concerned about the level of the fever and the fact that after 3 days he is not improving.
Discussion Questions Part One We will begin by focusing on gathering history in an ill child.
What ‘red flags’ did you note in the historical data?
What data is most important to include in this particular case and which historical data that might be gathered on a well-child exam can be left out of this ill visit?
What are your differential diagnoses?
What parts of the physical exam will you focus on today to rule in or out your differentials?
Discussion Part Two (graded)
Physical Examination Riley:
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%
Discussion Questions Part Two
After reviewing the physical exam.
What were your ‘red flags’ on physical exam?
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: Tympanic membranes intact with scant clear fluid posteriorly bil and mild injection. 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.
Neck: supple w/mild anterior cervical lymphadenopathy bil.
Lungs with mild expiratory wheeze in posterior bases
What are your primary, secondary, and differential diagnoses now?
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