Pediatric Presentation

Based on the case presented, the most appropriate triage score is 4. This indicates that the condition is severe and needs immediate attention. However, the condition is not critical (as this would be given a higher score, and is accompanied by major physiological and psychological symptoms). The provisional diagnosis or potential problems are gastroenteritis, food allergy, or adrenal insufficiency. The key elements when taking a history for pediatric presentations are history of the presenting illness, prenatal and birth history, immunization history, developmental history and medication history. A pediatric history, like an adult history, investigates the patient's primary concern or concerns and must be tailored to the individual presenting complaint (Wyly, 2018). In general, you should try to characterize the clinical signs of concern and get a clear understanding of the onset, timing, aggravating and relieving factors, related symptoms, and whether anything similar has happened to the patient before (Sutcliffe & Radonovich, 2020). Pregnancy and birth history are essential for assessing whether the neonatal period contributed to the illnesses. Here, the clinician evaluates prior breathing problems, feeding problems, and use of oxygen during the neonatal period.

The immunization history informs the clinician about the patients that will need a particular examination. It will also help in narrowing down the possible diagnosis based on the vaccinations received as an infant. It discusses any developmental delays, psychological issues, health and behavioral concerns, family and cultural factors that could result to the infant's current condition (Rabbitt, 2018). The medical history also provides essential information on the infant's potential strengths and potential to fight infections. Aside from preventing prescription errors, accurate medication histories can help prevent prescription errors and detect drug-related pathology or changes in clinical symptoms that may be caused by drug therapy.

In this case, the clinician should recommend antipyretic therapy because the intervention is used to improve the overall comfort of the child when the temperature gets higher than 38.3. The high fever can be signs of bacterial or viral infections. In this regard, the professional should carry out a full body diagnosis and evaluate the best treatment course that will improve the infant’s health. Electrolyte levels in the body may become too low or too high (Narahari et al., 2021). When the water content in your body changes, it causes an electrolyte imbalance. The amount of water you consume should be equal to the amount you lose. When something throws this balance off, a patient may dehydrate (have too little water) or overhydrate (having too much water). Some prescription drugs, vomiting, excessive sweating, diarrhea, and liver or kidney problems can disrupt the water and electrolyte balance.

There are a number of parameters that need to be measured to assess the level of electrolyte imbalances. The most important parameter to be collected for actual and potential fluid and electrolyte imbalances is blood test. An anion gap blood test is a calculation performed using the results of an electrolyte panel, a form of blood test (Hekmatnia & Pak, 2017). To accurately obtain the data, the health care professional will draw blood from a vein in the patient's arm with a small needle. Following the insertion of the needle, a small amount of blood will be collected in a test tube. A high anion gap test result will mean that the patient may have acidosis while a low anion gap test result may imply that the patient has alkalosis.

References

Hekmatnia, A., & Pak, N. (2017). Pediatric MSK Case Presentation Session. Iranian Journal of Radiology, Special iss(5). https://doi.org/10.5812/iranjradiol.48346

Narahari, P., Fanous, H., Matheus, C., Markland, K., Saad, A., & Gregoire-Bottex, M. M. (2021). An Atypical Presentation of Pediatric Sarcoidosis. TP70. TP070 DIFFUSE LUNG DISEASE and RARE DISEASE, 3(12). https://doi.org/10.1164/ajrccm-conference.2021.203.1_meetingabstracts.a3279

Rabbitt, A. L. (2018). Irritable Infant. Nelson Pediatric Symptom-Based Diagnosis, 411-420.e2. https://doi.org/10.1016/b978-0-323-39956-2.00026-1

Sutcliffe, M. S., & Radonovich, K. J. (2020). Psychological Assessment. Pediatric Rehabilitation. https://doi.org/10.1891/9780826147073.0004

Wyly, M. V. (2018). Assessing Information Processing. Infant Assessment, 100–121. https://doi.org/10.4324/9780429499807-5

Wyly, M. V. (2018). Assessment of Developmental Status: Issues and New Directions. Infant Assessment, 193–208. https://doi.org/10.4324/9780429499807-9