IHuman Case Study 2 Years Old Child Reason For Encounter Ear Pain And Fever

WALDEN UNIVERSITY IHUMAN CASE STUDY 2 YEARS OLD CHILD REASON FOR ENCOUNTER

EAR PAIN AND FEVER

PATIENT INFORMATION

AGE: 2 YRS OLD

Sex: Female

HEIGHT: 2’ 9” (84cm)

WEIGHT: 27.0lb(12.3kg)

REASON FOR ENCOUNTER: EAR PAIN AND FEVER

2 | P a g e

Chief Complaint (CC)

"My son has been tugging at his right ear and has a fever since yesterday."

History of Present Illness (HPI)

The patient is previously healthy 2-year-old boy brought to the clinic by his mother. She reports that he has had a fever (Tmax 39.0°C) for the past 24 hours, associated with decreased appetite and irritability. He has been tugging at his right ear frequently and crying more than usual. No vomiting or diarrhea. No known ear discharge. He has had a runny nose and nasal congestion for 3 days prior to onset of ear pain. No recent travel or sick contacts known.

The following table summarizes your performance on each section of the case, whether you completed that section or not.

Time spent: 1hr 18min 17sec Status: Submitted

3 | P a g e

4 | P a g e

History Notecard

Use this worksheet to organize your thoughts before developing a differential diagnosis list.

1. Indicate key symptoms (Sx) you have identified fromthe history. Start with the

patient's reason(s) for the encounter andadd additional

symptoms obtained from further questioning.

2. Characterize the attributesof each symptom using "OLDCARTS". Capture

the details in the appropriate column and row.

3. Review your findings and consider possible diagnoses that may correlate with these

symptoms. (Remember to consider the patient's age and risk factors.) Use

your ideas to help guide your physic al

examinatio n

in the nex t

sectio n

of the case.

5 | P a g e

Problem Statement

Gemma Jonesis a 2yo female that presents with a new onset rash of her abdomenthat has worsened spreadingto all four extremities. On

assessnet there

She has

nonproduc

tive

is

no

cough ,

a

oth

er

run

ny

maculopapul ar

significant

nose,

an

d

pink

medi

cal

fever

rash

histor

y. 3

on

Sh

e

da

ys

the

recen

tly

ago;

abdomenan d

experience

d the

fev

er

extremities.

a

resolved yesterday.

Intake and outpu t

have been norm al

per mothe r's

report .

6 | P a g e

Management Plan

Subjective: Complains of cough, runny nose, fever and new onset rash. Fever started 3 days ago and stopped last evening. Cough and rhinorrhea also started 3 days ago.

Objective: Presents with rhinorrhea and acute cough. Skin is warm and dry but

a maculopapul ar

fever at this

Diagnostics: No

URI but none

pink

time.

testi

ng

are

rash

is

necess

ary

on

necess ary

.

the

.

abdomenand

Can test

extremities

IgM and

is

obtain

presen t.

chest

No

xray for

Assessment: The presentation of cold symptoms and fever before the rash

appeared supports the diagnosis of

roseola .

The patient had a cough and runny nose

along with fever that has

the leading diagnosis.

subdue d

and was follow ed

by a rash, theref or

roseol a

is

Plan: Reassurance that rash will resolv

e

on its own in a few days,

promote rest and hydrati on

and expect a full recove ry

in approximately 1 week.

Education: It may take 5 to 15 days for a child to have

symptoms of roseolaafter being expos ed

to the virus. Once the fever is gon e

for 24 hours ,

the diseaseis no longer contagious. Even if the rash is

still presen t,

your child can return to child care or school .

Childr en

expos ed

to you r

child earlier may come down with roseol a

in 9–10 days.