Kiwiology Posted November 17, 2013 Posted November 17, 2013 You are called to see a three year old female child at home. It is 11.30 pm and mum states her daughter has been unwell for approximately 16 hours since 8.00 am this morning when she woke her to go to pre-school. HPI 16/24 generally unwell; has vomited once (stomach contents), no diarrhoea O/A In bed, awake, alert, orientated for age, not in obvious distress. She prefers to be in bed with blankets over her C/O “feels sick” – unable to be more specific O/E V/S: BP 100/70 PR 100 RR 40 T 37.5° SpO2 99% RA BGL 3.3 (~70) GCS 15 EXTREMITIES: Without cyanosis, clubbing or edema. Skin: WPD w/o purpura. NEURO: NAD HEENT: Denies sore throat, PERL (somewhat sensitive to pupillary light), otherwise NAD NECK: Supple w/o lymphadenopathy. CVS: NAD, normal S1/S2 w/o adventitious sounds RESP: Air entry clear/equal, no adventitia, no cough ABDO: Soft, non-tender, no distension, good bowel sounds. Inguinal area is normal. Consider … (1) What is your provisional diagnosis? (2) Are there any “red flags” which you think this child needs immediate referral to a Doctor? (3) If so, how quickly should she be seen by the Doctor upon arrival? Immediately? 10 minutes? 30? 60? 120? (4) What treatment would you provide right now and why?
Kiwiology Posted November 17, 2013 Author Posted November 17, 2013 The RR being 40 is a huge red flag. Why? What is the normal respiratory rate for a 3 year old? So do you think that warrants the child being immediately referred to a Doctor? Do you see any other red flags here?
MariB Posted November 17, 2013 Posted November 17, 2013 The respiration rate is high for a child that age at rest. Any three year old who generally acts unwell, probably is. Before jumping to rush to the doctor, we would need a lot more of this child's history. However, calling 911 will usually get you to the doctor pretty fast, not sure how long it will take you to be seen. And your bgl and temp have me off as I'm used to gifferent readings and too tired and lazy
Kiwiology Posted November 17, 2013 Author Posted November 17, 2013 The respiration rate is high for a child that age at rest. Any three year old who generally acts unwell, probably is. Before jumping to rush to the doctor, we would need a lot more of this child's history. However, calling 911 will usually get you to the doctor pretty fast, not sure how long it will take you to be seen. And your bgl and temp have me off as I'm used to gifferent readings and too tired and lazy So, do you know what the normal respiratory rate for a 3 year old is? What if its 20? or 30? or 35? How will that change the way you look at it given the overall clinical picture? The BGL is in both mmol/l and mg/dl; the temp in F is 99.5, apologies. What do these numbers tell you? Just because mum called 911 doesn't mean the child needs to be seen by a doctor tonight. What I am asking is do you think she needs to be seen by a doctor tonight, and if so, how soon? i.e. how much of a threat to her life is your diagnosis?
MariB Posted November 17, 2013 Posted November 17, 2013 Yes, 30ish to 35ish . How much has she been drinking? Does she have a medical history? Why did mom feel the need to call? Meds?
BEorP Posted November 17, 2013 Posted November 17, 2013 O/A In bed, awake, alert, orientated for age, not in obvious distress. She prefers to be in bed with blankets over her Does she want the blankets over her head specifically?
scubanurse Posted November 17, 2013 Posted November 17, 2013 (edited) any neck stiffness d/t the blankets over the head and sensitivity to light (photophobia?) You can be seeing early meningitis (no rash yet). Edited November 17, 2013 by scubanurse
Kiwiology Posted November 18, 2013 Author Posted November 18, 2013 Yes, 30ish to 35ish . How much has she been drinking? Does she have a medical history? Why did mom feel the need to call? Meds? Yes what? OK so if the normal respiratory rate for a 3 year old is 30-35 then what does her RR being 40 mean to you? PMHx NAD Mum called because she doesn't know what to do No regular Rx Does she want the blankets over her head specifically? Hard to tell, she wants to hide under her covers in general ... any neck stiffness d/t the blankets over the head and sensitivity to light (photophobia?) You can be seeing early meningitis (no rash yet). No neck stiffness that we can illicit but it's a crook 3 year old so .... Could be meningitis, could be anything ...
ERDoc Posted November 18, 2013 Posted November 18, 2013 Can you convince her to look down at her bellybutton?
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