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(2013, February 15). Evaluation of fever in infants and young children.
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Hay, W., Levin, M., Deterding, R.,
& Abzug, M. (2014). Current diagnosis and treatment: Pediatrics (22nd ed.).
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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