Cheryll is a 4-month-old girl brought to the pediatric clinic by her mother. Until 2 days PTA, she has been in good health. She has had diarrhea, vomiting, and decreased intake for 2 days. Cheryll 's mother, father, and 3- year-old brother all had the same symptoms but are now improved. Subjective Cheryll has less diarrhea and no vomiting today, but she doesn't want to breastfeed and still appears to be "more sleepy than usual and just not herself." Her mother reports, "Now that I think about it, Cheryll has only had 1 or 2 wet diapers since yesterday." Objective Vital signs: Temp 99.5° F (37.5° C, rectally). BP 68/46 mm Hg (while lying being held). Pulse (apical) while sleeping 164 bpm, rhythm regular, force 2+. Resp 56/min. Weight 11 Ib, 4 oz (5.2 kg). General appearance: Listless, pale; appears to be sleeping in mother's arms and awakens to physical stimuli but does not cry. HEENT: Anterior fontanel sunken; dry oral mucosa; no tear production. Cardiovascular: Tachycardia; no abnormal heart sounds; femoral pulses 1+ = bilat. Respiratory: Tachypnea. Pulse oximetry 94% on room air. Breath sounds clear in all fields and = bilat; no adventitious sounds. Abdomen: Hyperactive bowel sounds; no palpable masses. Extremities: Cool, decreased pulse, cap refill 4 sec. What is your assessment to Cheryll? Why you came up with that assessment?
Cheryll is a 4-month-old girl brought to the pediatric clinic by her mother. Until 2 days PTA, she has been in good health. She has had diarrhea, vomiting, and decreased intake for 2 days. Cheryll 's mother, father, and 3- year-old brother all had the same symptoms but are now improved. Subjective Cheryll has less diarrhea and no vomiting today, but she doesn't want to breastfeed and still appears to be "more sleepy than usual and just not herself." Her mother reports, "Now that I think about it, Cheryll has only had 1 or 2 wet diapers since yesterday." Objective Vital signs: Temp 99.5° F (37.5° C, rectally). BP 68/46 mm Hg (while lying being held). Pulse (apical) while sleeping 164 bpm, rhythm regular, force 2+. Resp 56/min. Weight 11 Ib, 4 oz (5.2 kg). General appearance: Listless, pale; appears to be sleeping in mother's arms and awakens to physical stimuli but does not cry. HEENT: Anterior fontanel sunken; dry oral mucosa; no tear production. Cardiovascular: Tachycardia; no abnormal heart sounds; femoral pulses 1+ = bilat. Respiratory: Tachypnea. Pulse oximetry 94% on room air. Breath sounds clear in all fields and = bilat; no adventitious sounds. Abdomen: Hyperactive bowel sounds; no palpable masses. Extremities: Cool, decreased pulse, cap refill 4 sec. What is your assessment to Cheryll? Why you came up with that assessment?
Chapter17: Drugs And Dissection
Section: Chapter Questions
Problem 1.2CS
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Assessment of Patient 3
Transcribed Image Text:Cheryll is a 4-month-old girl brought to the pediatric clinic by her mother. Until 2 days PTA, she has been in
good health. She has had diarrhea, vomiting, and decreased intake for 2 days. Cheryll 's mother, father, and 3-
year-old brother all had the same symptoms but are now improved.
Subjective
Cheryll has less diarrhea and no vomiting today, but she doesn't want to breastfeed and still appears to be
"more sleepy than usual and just not herself." Her mother reports, "Now that I think about it, Cheryll has only
had 1 or 2 wet diapers since yesterday."
Objective
Vital signs: Temp 99.5° F (37.5° C, rectally). BP 68/46 mm Hg (while lying being held). Pulse (apical) while
sleeping 164 bpm, rhythm regular, force 2+. Resp 56/min. Weight 11 Ib, 4 oz (5.2 kg).
General appearance: Listless, pale; appears to be sleeping in mother's arms and awakens to physical
stimuli but does not cry.
HEENT: Anterior fontanel sunken; dry oral mucosa; no tear production.
Cardiovascular: Tachycardia; no abnormal heart sounds; femoral pulses 1+ = bilat.
Respiratory: Tachypnea. Pulse oximetry 94% on room air. Breath sounds clear in all fields and = bilat; no
adventitious sounds.
Abdomen: Hyperactive bowel sounds; no palpable masses.
Extremities: Cool, decreased pulse, cap refill 4 sec.
What is your assessment to Cheryll? Why you came up with that assessment?
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