Pediatric case report sent

Case Report: Pediatric Case Study
Patient ID: S. G
History and Physical conducted by:
History and Physical conducted on:
Source: Information given by S.G mother
Chief Complaint: Mother reports the child has been having fever for 3 days and developed face
rash 1 day ago.
History of Present Illness
Mother says that the ailment of her daughter started with fever and running nose three days
before coming to the hospital. She reports that fever had raised up to 102 F the previous night
which she treated with syrup ibuprofen. Mother further stated that she does not know exactly
how much of ibuprofen has been given, but only the amount that is stated in the medicine bottle.
However the mother stated that her child woke up with a painless rash that morning that seems
like somebody has slapped on her face. The mother says she’s worried that something grave
could be, so she decided to bring her to the clinic.
Past Medical History
Pregnancy: Mother reported history of high blood pressure in the prenatal period.
Neonatal period: S.G was born at 38 week through spontaneous vaginal delivery. She left the
hospital after 4 days since she developed fever after birth. Weighed 3.5 kg. Mother states that
S.G developed mild jaundice which resolved spontaneously after five days.
Hospitalizations: Mother said her child was generally health kid with no history of
hospitalization.
Accident: S.G had broken her left forearm a year ago after falling from the seat. Said the mother.
Preventive care: Had visited her pediatrician 2 months ago for routine checkup.
Surgeries/procedures: S.G mother denied any surgical history.
Other active problems: Mother died any active problem
Medications: Mother said S.G was taking multivitamin every day and ibuprofen when
necessary.
Immunizations: Mother said her daughter immunization is up-to-date, having received her
annual flu vaccine 2 months ago.
Allergies: No Known food and Drug Allergies.
FH: Mother stated that she suffers from hypertension but the father is generally healthy. No
history of physical or mental disorders.
Developmental history: Mother reported that S.G sat at 6 months and started to crawl at 10
months and walked at 12 months. At 13 months she started mentioning ‘mama’. At her current
age of 5 she can recite alphabets and skips around.
SH: S.G Lives with her mother, father and her elder sibling. Father is an accountant and works in
the bank and mother works in local restaurant. In the first four years of her life, S.G was taken to
a day care and mother said she did not have any problem at the day care. S.G is now attending
kindergarten at a local elementary school and her mother return from work at two p.m. and pick
her daughter. S.G usually have sport activity after school.
ROS
General –Mother reported that her daughter had fevers the previous night but no chills; she also
stated her child’s appetite had reduced.
HEENT:
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Head – denies dizziness, headache, or syncope
Ears – mother denies any changes in her hearing or ear discharge.
Eyes – mother denies problems in her daughter eyes.
Nose – Clear nasal discharge.
Throat – mother denies any cough or sore throat for S.G.
Cardiovascular – No chest pain reported or palpitations for S.G
Pulmonary –No shortness of breath, wheeze or cough was reported.
Gastrointestinal – Mother states that S.G.’s appetite is normally good but had reduced for the
past three days. However, no vomiting, diarrhea or difficulties in swallowing was reported.
Genitourinary – mother denies history of dysuria, increased frequency or UTI
Neurologic – mother denies history of seizures or fainting, said S.G had good memory.
Musculoskeletal – mother reports history of left broken forearm
Endocrine – mother reported S.G has grown with normal limit, and denies any endocrine related
symptoms.
Hematopoietic – No history of anemia or easy bruising was reported for S.G
Physical Exam
S.G is fairly talkative and calm kid. She is alert and oriented to time place and person. She
appeared well nourished and in good hygiene. She does not appear to be in any acute distress but
looks a bit lethargic. The patient can move around without difficulties.
Vital signs: Height 107 cm Weight 16kg Heart rate: 85 respiratory Rate 25 BP 101/62 Temp 101
F0. SPO2 99%
General: S.G does not appear to be in any acute distress.
HEENT: Head- No hair loss, Eye- Symmetrical with no nystagmus or ptosis, pupils react equally
to light. Ears- No any lesion, tenderness or discharge, Nose- Has Normal nares but right
turbinate is swollen. Throat- no erythema in S.G throat and no inflamed tonsils.
Lymph nodes: No palpable or tender lymph nodes.
Neck: S.G’s Trachea is not deviated and no palpable masses.
Cardiovascular: Regular rate and rhythm; normal S1, S2; no murmurs, rubs, or gallops. Point of
maximal impulse at 4th intercostal space.
Lungs: lungs are bilaterally clear to auscultation. No wheezes or crackles
Abdominal:
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Abdomen soft, flat and non-tender, normal bowel sounds.
No palpable mass and no tenderness in all four abdomen quadrants.
Liver palpable 2cm below the costal margin the span is 5 cm.
Rectal: No any lesions noted.
Genital-urinary: No discharge, lesions or abnormality noted
Neurologic: S.G is oriented to time, person and place. No any acute distress noted but appear a
bit lethargic. S. G has normal reflexes.
Musculoskeletal: Joints are normal, range of movement is normal, no spinal tenderness or
deviation from midline.
Laboratory Data: None collected
Diagnostic Tests: Upper respiratory tract infection (URTI)/ Allergic Reaction
Problem List
1. Fever
2. Rashes in the face.
Problem Fever and face rash
Differential diagnosis: Viral infections, Pneumonia, Bacteremia, UTI.
Discussion:
For older kids and children without immune problems, fever is described as anything
above 101.2 degree Fahrenheit. It can be higher if other areas like orally or rectally are used. The
body has various mechanisms of maintaining normal body temperature (Texas Children’s
Hospital, 2018). The organ that supports the regulation of temperature includes the brain, skin,
muscles and blood vessels. The main risk factor for S.G getting fever is her age which increases
risk of acquiring viral or bacterial infections. The fever could mean presence of either bacterial
or viral infections. Clinically, it is likely that S.G is suffering from upper respiratory infection
which is mainly caused by viral infections. URTI can manifest with similar symptoms as
manifested in S.G. (Running nose, fever and decreased appetite).
Manifestation of face rashes is likely to be caused by due to allergic reaction caused by
ibuprofen. Adverse reaction to pediatric ibuprofen, which is an acute urticaria and a fixed drug
eruption, has been reported in pediatric (Jara, 2019). However it is normally not severe to
majority of children
Diagnostic plan: Complete blood count to get the blood picture for other potential infections.
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Treated with cetirizine (antihistamine)
Changed syrup Ibuprofen to syrup Acetaminophen.
Patient Education: The importance of seeking medical attention immediately the child develop
problem and avoid over the counter medications.
References
Jara, D. (2019). Allergic reactions due to ibuprofen in children. PubMed. doi:DOI: 10.1046/j.15251470.2001.018001066.x
Texas Children’s Hospital. (2018). Texas Children’s Hospital. Retrieved from Fever in Children:
https://www.texaschildrens.org/health/fever-children
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