Question

Thomas Smith Case Study Thomas Smith (DOB 7/17/2008) is an elementary school student brought to your office by his mother. Thomas has had a fever and a sore throat for 24 hr. He is normally healthy and he has never had any gurgery. Other children in his classroom have been ill with similar symptoms. Thomas has no siblings and he lives with both his mother and father. There are no smokers in his household. He has no difficulty swallowing. He has not vomited or had diarrhea. His mother states that Thomas has had a decreased appetite but that he is drinking liquids. Thomas takes no medications and his mother has not given him anything for his fever. His mother said that Thomas has no known allergies. You take his vital signs as follows: BP 90/60 mm Hg; HR 100 bpm and regular respiratory rate 20 breath/min; temperature (oral) 103.5 F. 1. Enter the patient data into the medical record

Answer 1

1. ANSWER :

NAME: Thomas Smith

AGE : 10 Years

SEX: Male

EDUCATION : Elementary school child

PRESENT MEDICAL HISTORY : Child came to hospital along with his mother with the complaints of fever and sore throat since one day, decreased appetite,no history of vomiting and diarrhea, as said by mother

PAST MEDICAL HISTORY : Nil significance of past medical history

PRESENT AND PAST SURGICAL HISTORY : Nil significance of present and past surgical history

HISTORY OF ALLERGIC REACTIONS : No evidence of any type of allergies

FAMILY PERSONAL HABITS : No history of smoking by father

NUMBER OF FAMILY MEMBERS : 3 Members

VITAL SIGNS :

T - 103.5 F

P - 100 bpm

R - 20 breath/ min

B.P - 90/80 mm Hg

2. ANSWER :

PRECAUTIONS TO BE TAKEN WHILE CONSIDERING PRESENT ILLNESS OF CHILD:

* Monitor vital signs of child

* Administer antibiotic drugs to child to prevent infection. Example : Ibuprofen

* Advice bed rest to child

* Educate mother to give plenty of oral fluids to reduce body temperature

* Place child in a comfortable position

* Provide ice creams, freezing products to child to reduce sore throat pain