Case Study 2

Presenting Complaint:
4 year old male [Ryan] presents with difficulty breathing. Mum states child has been tired in the last week and irritable. Noticed red rash on hands two days ago thought it was a reaction to grass as child had been spending a lot of time outside recently; itching profusely today with lack of sleep child has started to stress. Coughing started 1hr ago mum gave 12xpuffs Ventolin with no relief.
Past history:
-Asthma with previous ICU admission when he was three.
-Vaccinations up to date
Vital signs:
-BP 110/72
-HR 143
-O2 Sats 92% on RA
-Temp 37.3
-Resps 34

Table of Contents

Systems review

NEUROLOGICAL: GCS is 14/15 with pupils equal and reactive to light (PEARL), varies between sleepy and unsettled.
RESPIRATORY Inspection: child is slightly distressed, speaking in short sentences, moderate intercostal recession.
Palpation: Chest expansion is symmetrical and there is slight tracheal deviation. There is no tenderness, lumps or lesions on the thorax.
Percussion: Resonance over all lung fields
Auscultation: There is equal air entry into all lung fields. Bronchovesicular breath sounds can be heard with an I:E (Inspiratory/expiratory) ratio of 1:2. Slight wheeze is present on expiration.
CARDIOVASCULAR Inspection: The patient is pale; slight peripheral cyanosis is present.
Auscultation: Heart sounds of S1 & S2 are heard. There is no murmur.
Chest radiograph showed clear lung fields.
INTEGUMENTARY: inspection Non-blanching purple spots over torso, blanchable raised red rash over hands-itchy.

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