Exam (elaborations) NR 511 Week 3 SOAP NOTE Riley 18 Months Subjective Chief Complaint Fever And Rash

Exam (elaborations) NR 511 Week 3 SOAP NOTE Riley 18 Months Subjective Chief Complaint Fever And Rash Chief complaint: fever and rash History of present illness (HPI): O: Onset-three days ago and is of normal levels in the morning then gets as high as 100 to 101 degrees in the afternoons. L: Location— developed a red, diffuse rash to the torso and abdomen D: Duration-three days C: Characteristics/Associated symptoms- clear rhinorrhea in the last 24 hours. Rash that does not itch and a barking cough in the last day. Not eating, not playing, minimal drinking. A: Aggravating factors-not discussed R: relieving factors- temporary relief of coughing after robitussin for the cough, and tylenlol for fever T: Treatments- 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. S: Severity- Mother is very concerned about the level of the fever and the fact that after 3 days he is not improving. Past Medical History- Born at 34 weeks gestation via cesarean section, weight. 5 pounds 1 ounce. The mother developed preeclampsia and gestational diabetes. The mother quit smoking when she found out she was pregnant. Riley has allergies per mother and sometimes takes Cetrizine syrup 2.5ml once daily, PRN congestion, and a children’s chewable multivitamin daily. immunization history- Birth – Hep B, 2 months – DTaP, COMVAX, PCV13, IPV, 4 months - DTaP, COMVAX, PCV13, IPV, 6 months – DtaP, PCV 13, IPV, Hep B Family History- They are maternal and paternal smokers. The mother has been one since age 22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no diseases reported in either parent. Kayla has a history with gestational diabetes. Mary has a history of hyperlipidemia, Type 2 DM, and Hypertension. They are Latin American in descent, emigrated from Cuba in the 1970s. Tom has a history of hypertension, hyperlipidemia, and an MI with stenting 2 years ago. The mother has two siblings; one who died in an MVA 5 years ago at the age of 18 a younger brother, and an older sister who is 42 and lives in a large urban city in the Midwest with her family, and she is in good health but also had PCOS and difficulty conceiving. Other family members died of old age. She is unaware of paternal familial health history. Field Family: Mother: Kayla-age 37, Father: Mike-age 39, Daughter: Lily-age 15, Daughter: Joage 5, Son: Riley-age 13 months. Maternal Grandmother: Mary-age 55, Paternal Grandfather: Tom-age 62 This study source was downloaded by from CourseH on :40:24 GMT -05:00 This study resource was shared via CourseH NR 511 Week 3 SOAP NOTE Riley 18 Months Subjective Chief Complaint Fever and Rash Social History- Both children currently live with their mother and maternal grandparents for the last 8 weeks. Their father is involved but lives several hours away where he works. Review of Systems: Constitutional: fever Neurologic: not reviewed Head/Eyes/Ears/Nose/Mouth/Throat: rhinorrhea Integumentary: red rash on torso and abdomen Cardiovascular: not reviewed Respiratory: barking cough Genitourinary: urinating Gastrointestinal: decreased appetite Musculoskeletal: not reviewed Hematologic: not reviewed Endocrine: not reviewed Objective Vital signs: 18 months-height: 85 centimeters (83rd percentile), weight: 13 kilograms (83rd percentile), Prior Visit: 13 months-height: 83 centimeters (98th percentile); head circumference: 48 centimeters (85th percentile), weight: 13.3 kilograms (98th percentile) 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: Light erythema noted to the cheeks bil. 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 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 This study source was downloaded by from CourseH on :40:24 GMT -05:00 This study resource was shared via CourseH Assessment Primary Diagnosis 1. Roseola (ICD 10: B08.2) – Pathology: According to Allmon, Deane, and Martin (2015) roseola is caused primarily by human herpesvirus (HHV)-6, and sometimes by HHV-7. The incubation period ranges from 1 to 2 weeks. Human herpesvirus (HHV)-6 and HHV7 are most likely to be spread through respiratory secretions in asymptomatic contacts (Allmon et al., 2015). HHV-6 and HHV-7 DNA may be found in saliva for extended periods of time following primary infection. It downregulates expression of CD3 on T cells, thus acting as a potential immunosuppressant. a. Signs and symptoms of this disease include: fever lasting 3-5 days, runny nose, irritability, and tiredness. As the fever subsides a rash may appear on the face and body (Allmon et al., 2015). 2. Croup (ICD 10: J05.0) – According to Researchers Zoorob, Sidani, and Murray (2011) the symptoms of this disease process is the result of an upper-airway obstruction due to generalized inflammation and edema of the airways. At the cellular level this progresses to necrosis and shedding of the epithelium. The narrowed subglottic region is responsible for the symptoms of seal-like barky cough, stridor (from increased airflow turbulence), and sternal/intercostal in drawing. a. As evidence by the vignettes description of the lungs with mild expiratory wheeze throughout and barking cough Secondary Diagnosis 1. Fever unspecified (ICD 10: R50.9)- abnormal elevation of temperature Differential Diagnosis 1. Measles (ICD 10: B05.9) - Pathology: Measles virus is transmitted via droplets and infects epithelial cells of the nose and conjunctivae. According to White et al. (2012) the virus multiplies in these epithelial cells and then extends to the regional lymph nodes. Primary viremia occurs 2 to 3 days after infection, and measles virus continues to replicate in epithelial and reticuloendothelial system tissue over the next few days (White et al. 2012). a. Typically accompanied by a prodrome of significant cough, coryza, and conjunctivitis and an enanthem consisting of gray-white papules on the buccal mucosa (White et al., 2012). The exanthem is an erythematous maculopapular eruption that spreads cephalocaudally and usually persists for one week before it begins to clear (White et al. 2012). Additional signs and symptoms include: cough, fever, conjunctivitis, koplik spots, and maculopapular rash (White et al. 2012). This study source was downloaded by from CourseH on :40:24 GMT -05:00 This study resource was shared via CourseH 2. Enterovirus (ICD 10: B34.1) - Pathology: Enteroviruses and rhinoviruses are typically distinguished based on the temperature at which they grow and their sensitivity to acid treatment according to Martin et al. (2016). Enteroviruses generally live within the gastrointestinal tract, and are grow best under acidic conditions and at body temperature. In contrast, rhinoviruses thrive within the cooler environment of the nose and the upper respiratory tract, and are very sensitive to acidity (Martin et al. 2016). a. The exanthem associated with enterovirus is a nonspecific, maculopapular, erythematous eruption. Enterovirus often presents as aseptic meningitis. Other signs and symptoms include: wheezing, shortness of breath, limb weakness, rhinorrhea, cough, and sneezing (Martin et al. 2016). Plan 1. Medications Discontinue Robitussin (Allan et al., 2010) Pediatric dosage calculation: Dose: 10-15 mg/kg PO q4-6h prn; Max: 75 mg/kg/day up to 1 g/4h and 4 g/day Children’s acetaminophen suspension liquid 160 mg/5ml 5 ml by mouth ever 4-6 hours as needed for fever greater than 101.0 F Dispense: one 4 ounce bottle Do not exceed 4 doses in 24 hour period (Zoorob et al., 2011) Pediatric dosage calculation: 0.15 mg/kg/dose Dexamethasone sodium phosphate: 0.6 mg/kg intramuscularly as a single dose Give one dosage 7.8 mg (based on 13kg weight) intramuscular injection in office Dispense: 1 bottle Solution 0.5 mg.5ml (7.8 mg/0.5mg x 5ml=75 ml) Refill: 0 Potential Side effects: headache, slowed healing of cuts and bruises, thin, fragile, or dry skin, red or purple blotches or lines under the skin, skin depressions at the injection site, increased body fat or movement to different areas of your body, inappropriate happiness, difficulty falling asleep or staying asleep, extreme changes in mood changes in personality, depression, and possible increased sweating 2. Additional diagnostic tests: Not at this time 3. Patient education a. Wiping the body down with isopropyl alcohol should be strongly discouraged because alcohol can be absorbed through the skin and cause toxicity (Allan