Are the patients immunizations up to date

Reference no: EM133694909

Assignment:

CC/PMI: WB is a 13-month-old male brought to your clinic by his mother with a 3-day history of a "cold" and irritability. He has a mild, non-productive cough and runny nose, with increasing lethargy and irritability over the past 3 days. He began pulling on his left ear late last night and had a "rough night" sleeping.

. His appetite is poor and he feels warm to the touch. WB had a bout of otitis media 2 weeks ago. He also has a severe case of diaper rash. SH: WB lives at home with his parents and older sister (age 5). He does not attend daycare. No one in the house smokes.

Allergies: none Medication: Vitamin supplement daily Amoxillin (Amoxil®) 250mg TID - completed full course 3 days ago Immunizations: DPT, Prevnar and IPV at 2, 4 and 6 months of age; Hib and Hep B at 2 and 4 months Physical Exam: GEN: well-developed, well-nourished boy, crying, tugging on left earlobe. VS: HR 124, RR 30, T 100.5, Wt. 22lb HEENT: let tympanic membrane red and bulging, no exudates; scant clear, watery nasal discharge COR: WNL CHEST: good breath sounds, no rales or rhonchi ABD: soft, non-tender, positive bowel sounds GU: erythema, tenderness, and inflammation over the entire diaper area, vesicular lesions on periphery of redness Group 3 Case.

Questions:

1. What treatment would you recommend for this patient's upper respiratory infection?

2. What would you recommend, if anything, for the patient's diaper rash?

3. Are the patient's immunizations up to date? If not what needs to be done?

Reference no: EM133694909

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