Infant History and Physical Examination
Patient H & P
CC: A girl of three years old is admitted with high fever and suspected meningitis. The mother of the patient will be the source of history.
HPI: Our patient was well and healthy before developing some fever and congestion yesterday, which was controlled by the administration of Tylenol in the middle of the night. However, the fever persisted and remained at 103o F.
PMH: In the last eight months, the patient had episodes of Otitis, which was resolved by antibiotics.
Mother’s Obstetrical and birth history
Had nulliparous before conception and had proper prenatal care throughout the pregnancy. All relevant maternal screening were all negative. She had no uneventful vaginal discharges, and she did not drink, smoke, or use any drugs.
Growth and development
The patient had a last well-child check in the previous 18 months, and the next one was in a few weeks. The previous check showed that the child was meeting all milestones as required. The child was able to sit unassisted after seven months and was able to walk after 16 months. By 12 months, the child was able to speak two words, and within two years, she was able to brush her teeth.
Allergies: NKMA
- Negative lead screens after 12 and 24 months.
- Exposures: mother smokes; No pets.
- Get enough sleep; 9-11 hours per night
- Immunizations; up to date according to the mother
- Diet; eats white meat and eats read meat. Plenty of fruits and vegetables supplied
Physical Exam
- Temperature: 103.2 F
- Pulse: 120 regular
- Oxygen Sat: 98.4% in room air.
- Respiration: 32 beats/minute
- Height: 96cm
- Bodyweight: 16.5kg
- BMI:17.9
- Skin: No rashes or lesions
- General: appears unwell and lethargic.
Meningitis is the suspected cause of fever.
Diagnosis Plan: Urinalysis, electrolytes, blood culture, chest x-ray, and LP to test glucose, WBC, and proteins.
Treatment: Tylenol, after every four to six hours, will be given, administration of IV acyclovir, Claforan and IV Vancomycin to treat meningitis.