GU: Any signs of a urinary tract infection? Concentrated urine? Foul-smelling urine? Any difficulty with urination? Color of his urine? NEURO: Any associated headaches? Vertigo? Or stiff neck? O. Growth: Current Ht: 87cm (above 50 th percentile), & Wt: 14kg (around 90 th percentile). Previous visit Ht: 84cm, HC: 49cm & Wt: 13kg V/S: B/P: 80/48, T: 101 tympanic (no antipyretic), HR: 122 BMP/reg., Resp: 24, regular, SpO2: 98% Physical Examination: General: Somewhat listless, but cooperative throughout exam; rests quietly in his mother’s arms throughout the exam. HEENT: head normocephalic atraumiatic; PERRL, conjunctiva unremarkable; tympanic membranes intact bil; EAC unremarkable; pinna/tragus w/o tenderness; nares patent, mucosa injected, with edema in inferior and medial turbinates bil, and scant clear rhinorrhea ; pharynx unremarkable and tonsils are +1/4 bil; neck supple w/o lymphadenopathy bil.
Chamberlain College of Nursing CARDIOPULMONARY: Heart RRR w/o murmur; lungs are clear to auscultation throughout; peripheral pulses reg., equal., intact bil radial and pedal; capillary refill 4 seconds in the finger tips; GU: Abdomen rounded with hyperactive bowel sounds throughout and diffuse tenderness ; mucous membranes are sticky , but not overly moist. A. Primary Diagnosis 1. Acute Gastroenteritis (ICD9 558.9): Clinical manifestations of gastroenteritis include diarrhea, fever, vomiting, and abdominal cramps, which are reported in Riley. NIH.gov (2015), notes that dehydration, which may be associated with electrolyte disturbance and metabolic acidosis, is the most frequent and dangerous complication of gastroenteritis. 2. Dehydration (ICD9 276.51): Dehydration is a state of negative fluid balance that is most commonly caused by diarrheal illnesses. Children lose large amounts of water and salts through fever, diarrhea and vomiting ( Al Sabbagh, 2013) . Signs and symptoms of dehydration in toddlers may include dry or sticky mouth, few or no tears when crying, eyes that look sunken into the head, lack of urine for 12 hours (or only a very small amount of dark yellow urine), dry/cool skin, lethargy or irritability and fatigue or dizziness. Riley’s had vomiting, diarrhea and fevers. His cap refill is <4 seconds, has somewhat sticky mucus membranes and he is also listless during his physical exam, all these signs make dehydration a high probability for his primary diagnosis. 3. Fever (ICD 9 780.6): Fever is a normal response to a variety of conditions, the most common of which is infection (Ward, Edwards & Torchia, 2015). Fever occurs when the body's temperature is elevated as a result of the body's thermostat being reset to a higher- than-usual temperature. Pediatric fevers are defined as a temperature reading of 100.4 taken via rectum, ear or forehead (with rectal being the most preferred and accurate core temperature). Riley has a fever of 101 tympanic reading.
- Spring '20