Level 1: Fever – Physical Exam: Patient Information

How would you revise your DDX based on the physical exam findings?

How would you revise your diagnostic explanation?

  • VS: Height 28” (71cm) 50%, Weight 21.5lbs (9.8kg) 75%, Head Circumference 17.75” (45cm) 50%, HR 130, BP 100/65, RR 24, Temp 103.4, O2 saturation 98% on room air
  • General: Lethargic and falls asleep frequently, irritable when awake.
  • HEENT: Normocephalic, atraumatic, anterior fontanelle is open and about the size of a quarter, no recessed/bulging and soft to the touch. PERRLA, external nose normal, nasal mucosa pale and edematous with clear mucus, oropharynx erythematous posterior wall without tonsillar hypertrophy or exudate. TM are erythematous and opaque, decreased movement with insufflation, right side worse than the left, otoscopy caused discomfort, external canal non erythematous/edematous, no exudates/drainage
  • Neck: No tenderness, thyroid appropriate size with no nodules or asymmetry, no apparent pain with flexion of the neck.
  • Cardiac: Regular rate and rhythm, S1 and S2 heard, no other murmurs/clicks/gallops/rubs
  • Respiratory: Clear to auscultation, no wheezes/rales/rhonchi/rubs
  • Abdomen: Active bowel sounds, no tenderness to palpation, liver/spleen could not be palpated
  • Genital Rectal: Deferred
  • Extremities: Pulses strong and symmetric at femoral and radial arteries, no peripheral edema
  • Neuro: Moves all limbs spontaneously, no gross motor deficits, no apparent aversion to light.
  • Skin: Warm/pink, no lesions
  • Psych: Emotionally labile, tearful at times