Fever in child

HISTORY:

Fever for ‍ ‍hoursdays

Up to: ‍° ‍not measured, ‍persistentintermittent

Treatments tried: ‍noneacetaminophenibuprofen, ‍effectiveineffective

‍cough, ‍non-productiveproductive

‍sputum, ‍clearcolored

‍runny nose, ‍clearcolored

‍sore throat

‍shortness of breath

Vaccination status: ‍up-to-dateincompleteunvaccinated



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Head: fontanelles ‍soft, ‍normocephalic

Eyes: -R: ‍normal, -L: ‍normal, ‍

Ears: -R: ‍normal, -L: ‍normal

Nose: ‍clear, ‍nasal flaring, discharge ‍clear, ‍

Throat: ‍normalrednessexudate

Mouth: ‍normal

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Chest: ‍tenderness on ‍rightleft ‍

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Genital: ‍normal, testicles ‍normal, penis ‍normal, Tanner stage ‍

Extremities: ‍normal, ‍normal pulses, cap refill ‍< 3 sec> 3 sec

Skin: ‍no rash

Musculoskeletal: joints ‍ ‍normal, ‍no limited ROM



ASSESSMENT:

‍Viral illness ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Chest X-ray

- Covid test

- Throat swab

- Urine culture

- Blood work: ‍CBC, ‍CRP, ‍blood culture

- ‍Acetaminophen (Pediatric)

- ‍Ibuprofen (Pediatric)

- Encourage hydration

- Antibiotics if bacterial infection suspected

- Follow-up in ‍ ‍hoursdays

- Return if fever persists for more than 3 days, if new symptoms develop, or if condition worsens

- Referral to pediatrician if no improvement after 72 hours

- Go to ER if seizures, severe headache, stiff neck, or other signs of serious illness occur