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.
